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The impact of maladaptive schema on disordered eating :

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Title:
The impact of maladaptive schema on disordered eating : a collective case study
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Book
Language:
English
Creator:
Hurley, Susan
Publisher:
University of South Florida
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Tampa, Fla
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Subjects / Keywords:
Anorexia Nervosa
Bulimia Nervosa
Obesity
Compulsive Overeating
Core Beliefs
Dissertations, Academic -- Curriculum and Instruction -- Masters -- USF   ( lcsh )
Genre:
non-fiction   ( marcgt )

Notes

Abstract:
ABSTRACT: This qualitative study is based on the reality that disordered eating such as anorexia nervosa, bulimia nervosa, and compulsive overeating resulting in obesity represent a major and growing problem in community health. Treatment models using cognitive behavioral therapy suggest that those diagnosed with an eating disorder tend to judge themselves in terms of their body shape, weight, and eating habits. However, the recovery rate for those treated for an eating disorder that only addresses those three issues identified above is less than 60%. A number of quantitative studies have provided evidence that other maladaptive schema may contribute to bulimic and anorexic behaviors. Fewer studies have addressed this issue in relationship to compulsive overeating resulting in obesity. This collective case study further explored and identified other maladaptive schema associated with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity that interfere in the long term recovery. This case study will allow the participants to express thoughts and emotions surrounding their disordered eating in their own voices. This collective case study provides evidence that persons diagnosed with disordered eating have carried early life events into adulthood and that these events have created maladaptive schema which may be interfering in their recovery process.
Thesis:
Dissertation (PHD)--University of South Florida, 2010.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Susan Hurley.
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Title from PDF of title page.
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Document formatted into pages; contains X pages.

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usfldc handle - e14.4676
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ABSTRACT: This qualitative study is based on the reality that disordered eating such as anorexia nervosa, bulimia nervosa, and compulsive overeating resulting in obesity represent a major and growing problem in community health. Treatment models using cognitive behavioral therapy suggest that those diagnosed with an eating disorder tend to judge themselves in terms of their body shape, weight, and eating habits. However, the recovery rate for those treated for an eating disorder that only addresses those three issues identified above is less than 60%. A number of quantitative studies have provided evidence that other maladaptive schema may contribute to bulimic and anorexic behaviors. Fewer studies have addressed this issue in relationship to compulsive overeating resulting in obesity. This collective case study further explored and identified other maladaptive schema associated with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity that interfere in the long term recovery. This case study will allow the participants to express thoughts and emotions surrounding their disordered eating in their own voices. This collective case study provides evidence that persons diagnosed with disordered eating have carried early life events into adulthood and that these events have created maladaptive schema which may be interfering in their recovery process.
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The Impact of Maladaptive Schema on Disordered Eating : A Collective Case Study by Susan Hurley A dissertation submitted in partial fulfillment of the requirements of the degree of Doctor of Philosophy Department of Counselor Education Col lege of Education University of South Florida Major Professor: Herbert A. Exum, Ph.D Deborah Osborn, Ph.D. Carlos Zalaquett, Ph.D. John Ferron, Ph.D. Date Approved : August 17, 2010 Keywords: Anorexia Nervosa, Bulimia Nervosa, Obesity, Compulsive Overeating, Core Beliefs Copyright 2010, Susan Hurley

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Acknowledgments I would like to thank Dr. Herbert Exum for his support and encouragement throughout this doctorate process. Thank you for being available, listening with complete positive reg ard, and allowing me to grow, learn and better understand the person that I am today. I would also like to thank the other members of my committee, Dr. Debra Osborn, Dr. Carlos Zalaquett, Dr. John Ferron. Your support, has been invaluable and ultimately helped me to think carefully through this process. Thank you to my mother and sister who have expressed often how proud they are of my accomplishments. I appreciate their encouraging me forward and their excitement for my completion. I would also like t o thank my daughter, Heather, son, Jason, daughter in law, Catherine and grandson, Alex, for reminding me to come up for air and distracting me for a while with hiking, baseball, family meals, and providing perspective. M ost of all thank you to my husban d, Greg for his quiet encouragement, and his willingness to be chief cook and bottle washer Now it is my turn to support him through the same process. Lastly, I want to thank the 10 women who were willing to share their stories. I appreciate you r candi dness and ability to trust me to tell your story with dignity and hope for the future.

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i Table of Contents List of Tables ................................ ................................ ................................ ..................... iv List of Figures ................................ ................................ ................................ ...................... v Abstract ................................ ................................ ................................ .............................. vi Chapter 1 Introduction ................................ ................................ ................................ ...... 1 Introduction ................................ ................................ ................................ .............. 1 Background ................................ ................................ ................................ 1 Statement of the Problem ................................ ................................ ............ 5 Purpose of the Study ................................ ................................ ................... 6 Research Questions ................................ ................................ ...................... 7 Assumptions of the Study ................................ ................................ ............ 7 Conceptual Framework ................................ ................................ ................ 8 Definitions of Major Terms ................................ ................................ ......... 9 Limitations of the Study ................................ ................................ ............. 1 1 Summary ................................ ................................ ................................ .... 1 2 Organization of the Study ................................ ................................ .......... 1 3 Chapter 2 Literature Review ................................ ................................ ........................... 1 4 Anorexia Nerv osa ................................ ................................ ................................ .. 1 4 Compulsive Ov ereating Resulting in Obesity ................................ ........................ 1 7 Bulimia Nervosa ................................ ................................ ................................ .... 2 2 Analysis of Literature Review ................................ ................................ ............... 45 Summary ................................ ................................ ................................ ................ 48 Chapt er 3 Design and Methodology ................................ ................................ ............... 49 Design and Methodology ................................ ................................ ....................... 49 Research Issues ................................ ................................ .......................... 50 Research Design ................................ ................................ ......................... 5 1 Research Part icipants ................................ ................................ ................. 5 3 Participant Selection ................................ ................................ ...... 5 3 Participant Characteristics ................................ ............................. 55 Participant Descriptions ................................ ................................ 56 Cathy ................................ ................................ .................. 56 Laura ................................ ................................ .................. 57 Margaret ................................ ................................ ............. 57 Joan ................................ ................................ .................... 58

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ii Carla ................................ ................................ ................... 58 Jade ................................ ................................ .................... 58 Donna ................................ ................................ ................. 59 Jillian ................................ ................................ .................. 59 Monica ................................ ................................ ............... 59 Andrea ................................ ................................ ................ 60 Data Collection ................................ ................................ ................................ ............ 6 0 Question s ................................ ................................ ................................ .......... 6 1 Interview Procedure ................................ ................................ ......................... 6 2 Data Analysis ................................ ................................ ................................ ............... 6 4 Transcript Analysis ................................ ................................ .......................... 6 4 Data Or ganization ................................ ................................ ............................ 65 Data Coding ................................ ................................ ................................ ..... 66 Memo Writing ................................ ................................ ................................ .. 71 Audit Process ................................ ................................ ................................ ... 7 2 Establishing Trustworthiness ................................ ................................ ........... 7 3 Summary ................................ ................................ ................................ .......... 77 Chapter 4 Result ................................ ................................ ................................ .............. 78 Results ................................ ................................ ................................ .................... 78 Case Studies ................................ ................................ ................................ ........... 8 0 Comp ulsive Ov ereating Resulting in Obesity ................................ ............ 8 0 Cathy ................................ ................................ .............................. 8 1 Joan ................................ ................................ ................................ 9 0 Laura ................................ ................................ .............................. 99 Margaret ................................ ................................ ....................... 1 07 Bulimia Nervosa ................................ ................................ ...................... 1 15 Donna ................................ ................................ ........................... 1 16 Jade ................................ ................................ .............................. 1 23 Carla ................................ ................................ ............................. 1 33 Anorexia Nervosa ................................ ................................ .................... 1 42 Jillian ................................ ................................ ............................ 1 43 Monica ................................ ................................ ......................... 1 50 Andrea ................................ ................................ .......................... 1 55 Summary ................................ ................................ ................................ .............. 1 63 Chapter 5 Summary an d Conclusions ................................ ................................ ........... 1 69 Summary ................................ ................................ ................................ .................... 1 70 Statement of the Problem ................................ ................................ ............... 1 70 Methodology ................................ ................................ ................................ .. 1 71 Findings ................................ ................................ ................................ .......... 172 Compulsive Ove reating Resulting in Obesity ................................ ...................... 1 74 Conclusions Regarding Compulsive Overeating Resulting in Obesity ................................ ................................ ................................ ..... 1 84 Bulimia Nervosa ................................ ................................ ................................ .. 1 88 Conclusions Relating to Bulimia Ne rvosa ................................ ..................... 197

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iii Anorexia Nervosa ................................ ................................ ................................ 2 02 Conclusion s Regarding Anorexia Nervosa ................................ .............. 2 09 General Conclusions ................................ ................................ ............................ 2 11 Contributions of This Study ................................ ................................ ................. 2 17 Recommendations for Use ................................ ................................ ................... 2 20 Case Conceptualization ................................ ................................ ............ 2 20 Planning Interventions ................................ ................................ ............. 2 21 Training Implications ................................ ................................ ............... 2 21 Recommendat ions for Additional Re search ................................ ........................ 2 22 Limitations ................................ ................................ ................................ ........... 2 24 References ................................ ................................ ................................ ........................ 2 29 Appendices ................................ ................................ ................................ ....................... 2 36 Appendix A Sample Recruitment Letter 2 37 Appendix B Sample Recruitment Letter 2 38 A ppendix C Sample Questions 2 40 A ppendix D Informed Consen t 2 42 Appe ndix E Journal Log 2 46 Appendix F Words and Phrases Most Often Associated With Maladaptive Schema 2 47 Appendix G Coding Cathy 2 49 Appendix H Coding Joan 2 61 Appendix I Coding Laura 2 74 Appendix J Coding Margaret 2 86 Appendix K Coding D onna 2 97 Appendix L Coding Jade 3 08 Appendix M Coding Carla 3 20 Appendix N Coding Jillian 3 30 Appendix O Coding Monica 3 40 Appendix P Coding Andrea 3 49 Appendix Q Au ditor Background Information 3 59 Appendix R Auditor Letter of Attestati on 3 60 About the Author END PAGE

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iv Tables Table 1 B asic Demographic information ................................ ................................ .......... 56 Table 2 Relationship of maladaptive schema to each of the disordered eating categories ................................ ................................ ................................ ...... 71 ; 2 17

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v List of Figures Figure 1: Relationship among maladapti ve sch ema and disordere 8

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vi Abstract This qualitative study is based on the reality that disordered eating such as anorexia nervosa, bulimia nervosa, and compulsive overeating resulting in obesity represent a major and growing problem in co mmunity health T reatment models using cognitive behavioral therapy suggest that those diagnosed with an eating disorder tend to judge themselves in terms of their body shape, weight, and eating habits. However, the recovery rate for those treated for an eating disorder that only addresses those three issues identified abov e is less than 60% A number of quantitative studies have provided evidence that other maladaptive schema may contribute to bulimic and anorexic behaviors Fewer studies have addresse d this issue in rela tionship to compulsive overeating resulting in obesity. This collective case study further explored and identified other maladaptive schema associated with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesit y that interfere in the long term recovery This case study will allow the participants to express thoughts and emotions surround ing their disordered eating in their own voices. This collective case study provides evidence that persons diagnosed with dis ordered eating have carried early life events into adulthood and that these events have created maladaptive schema which may be interfering in their recovery process.

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1 Chapter One Introduction This chapter provides background information regarding the general state of eating disorders and current treatment concerns regarding the role of maladaptive schema. In addition, t he chapter explains the statement of the problem and the purpose of the study. At the end of the chapter is an outline indicating ho w the dissertation in total is organized. Background Disordered eating such as anorexia nervosa, bulimia nervosa, and compulsive overeating resulting in obesity represent a major and growing problem in community health. Recent studies from around the worl d suggest that the number of recorded cases is increasing across a wide range of ethnicities and cultures (Shiina et a l. 2005). In 1999 it was estimated that 8 mil lion women in the United States alone were diagnosed with anorexia nervosa or bulimia nervo s a (Wilson & Blackhurst, 1999) and when left untreated these disorders may become lethal (Neuman & Halverson, 1983 ). Treatment has been a major top ic of research for many years. Research in the comparison of various types of therapy used in the treatmen t of disordered eating suggests that cognitive behavioral therapy is considered the best choice ( Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Anderson & Malo ney, 2001; Hughes, Hamill, vanGe rko, Lockwood & Waller 2006 ; Leung, Waller & Thomas, 2000; L undgren,

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2 Danoff Berg & Anderson, 2003; Rose, Cooper & Turner 2006; Waller, Ohanian, Meyer & Osman, 1999; Wilson & Fairburn, 1993). In general, t he treatment protocol for cognitive behavioral therapy when treating eating disorders traditionally include s 20 outpatient sessions that focus on reducing symptoms and building skills (Young, Klosko, & Weishaar, 2003) The cognitive behavioral therapy protocol for the treatment of bulimia nervosa proposed by Fairburn & Cooper in 1989 included 19 sessions of in dividual treatment over the course of about 20 week s and focus ed on addressing (a) body shape, (b) weight, and (c) eating (Wilson & Fairburn, 1993) Treatment outcomes usually report a high rate of success at approximately 40 % t o 50% (Agras 1997; Anderson & Maloney, 2001). However, a study by Agras found that in the treatment of bulimia nervosa there was a 16% drop out rate and o f those remaining in treatment about 40% c ompleted the treatment and were considered to be in recovery. While a treatment succe ss rate of 40% is consider ed high, 50% to 60% of those seeking treatment fail to get results Of those women who complete treatment there is also a relatively high rate of relapse reported. Women treated for anorexia report a relapse rate of 36% and women treated for bulimia report a relapse rate of 35% (K eel, Dorer, Franko, Jackson, & Herzog, 2005). The limited scope of treatment focusing on body weight, shape and eating m ay provide insight into why approximately 36% of women treated for anorexia and bu limia relapse and why approximately 50% of those who do seek treatment do not recover Recent studies suggest that other maladaptive schemas may play a role in disordered eating and that identifying and including these maladaptive schema in treatment ma y

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3 increase the rate of recovery ( Rose et al.; Wall er, Ohanian et al. ) as well as decrease the rate of relapse Y oung Klosko, & Weishaar (2003) defined schema as a broad pervasive theme comprised of memories, emotions, cognitions, and bodily sensations r egarding oneself and These factors are developed during childhood or developed ways of thinking about themselves there is a strong tendency f or these schemas to be maintained, causing a bias in what is attended to, what is remembered, and what people are prepared to accept as true about themselves (Pervine & John, 2001) These schemas control or at least greatly influence how people process information. Maladaptive schemas are self defeating emotional and cognitive patterns that can repeat throughout f a schema is maladaptive, the n negative behaviors may develop in response which in turn dis tort life events in order to main tain that s chema (Young et al. ) Young et al., indicate schemas that develop as a result of toxic childhood experiences may be the core of many chronic Axis I disorders. A child who has been abandoned, abused, neglected, or rejected may experience some ty pe of life event as an adult t hat is p erceive d as similar to the childhood experience T his may trigger maladaptive schemas such as defectiveness/shame or mistrust/abuse which could cause a strong negative em otional reaction (Young et al. ). However, not all schemas are based in some type of childhood trauma. A person could be overprotected as a child and develop dependent/incompetence schema as an adult.

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4 While not all maladaptive schema are developed through childhood trauma they are all considered to b e destructive and most likely caused by some toxic, repetitive experience that has occurred during childhood and adolescence (Young et al. 2003) Because individuals perceive these schema as absolute truths they play a major role in how they think, feel act and relate to other people and as adults they continue to recreate their most harmf ul childhood experiences (Young et al.). The r esearch suggests that people with disordered eating who have experienced childhood trauma and developed maladaptive sc hema attempt to cope with the thoughts and emotions surrounding these experiences by either overeating, restricting or binging and purging (Cooper & Fairburn, 2001; Dingemans, Spinhoven & van Furth, 2006; van Hanswijck de Jonge, Waller, Fiennes, Rashid, La cey 2003; Waller, Meyer & Ohanian, 2001). Waller et al. (1999 ) found that binge eating and vomiting related to bulimia nervosa were associated with two maladaptive schema defectiveness/shame and emotional inhibition B inging and vomiting wer e believed to serve to reduce awareness of the se maladaptive schema and the emotional consequences that go with it. In their study of sexual abuse in morbidly obese women, van Hanswijck de Jonge et al. (2003) found that overweight or obese women strugglin g with sexual abuse had more negative core b eliefs including defectiveness/ shame, vulnerability to harm, social isolation, and subjugation W omen with a higher B ody M ass I ndex also carried stronger maladaptive beliefs regarding emotional deprivation, conc erns for abandonment, mistrust, social isolation, unrelenting standards, and subjugation. In a study of bulimia and m aladaptive schema, Leung et al. (2000) found that participants with more maladaptive core beliefs were less successful in treatment in a c ognitive behavioral

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5 therapy group Defectiveness/shame, isolation and social undesirability were considered high predictors of a failure to stop vomiting, or at the least reduce vomiting in bulimic participants. Statement of the problem Cognitive Behavi oral m odels of treatment suggest that people with disordered eating tend to judge themselves in terms of their eating habits, weight and body shape and they lack the ability to control these three maladaptive schema (Fairburn, Cooper & Shafran, 2003 ). However, the recovery rate when addressing eating habits, weig ht and body shape is less than 50% (Agras, 1997) T here is a lso a reported 36 % relapse rate for anorexia and 3 5 % for bulimia (Keele et. al. 2005) Several quantitative studies have provided evidence that other early maladaptive schemas may contribute to bulimic behaviors ( Leung et al. 2000; Meyer, Waller & Watson, 2000 ; Spranger, Waller, & Bryant Whaugh, 2001; Waller, Dickson & Ohanian, 2002 ). Fewer studies have addressed this issue in r el ationship to anorexia nervosa or compulsive overeating resulting in obesity, but the results do suggest similar findings Since approximately 50% of those seeking treatment for disordered eating fail to reach the recovery phase, and 36% of those individual s who are reported to reach the recovery phase of treatment relapse, t hen identifying and addressing other contributing maladaptive schemas may increase the rate of long term recovery. atients identify their maladaptive schema and are provided with coping styles, they may begin to exert some contr et al., 2003 p. 29) which may provide them better control over their disordered eating resulting in a happier more s uccessful recovery experience.

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6 Except for one, all the s tudies reviewed used quantitative measures. Waller as well as others grouped bulimia, anorexia binge/purge subtype, and binge eating disorders together and used small unequal sample sizes. Separating the disorders an d studying them individually through the use of a collective case study may yield an expansion on the specific maladaptive schema involved by allowing participants to describe their experiences in their own voices A qualitative approach will help to establish an empathetic understanding th rough thick description and a narrative approach which may provide the reader an opportunity to gain an experiential understandi ng of each case (Stake, 1995). Purpose of the Study The purpose of this study is to further explore and identify potential mala daptive schemas associated with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity that may interfere in long term recovery This collective case study will use a natural setting where participants may express in their own voices thoughts and emotions they have surrounding their dis ordered eating The words they provide will allow this researcher to interpret phenomena based on t he meanings people bring to it A pilot study conducted by Hurley (2008) identified maladaptive schema associated with bulimia nervosa anorexia nervosa and obesity. The study consisted of three individual case s E ach participant was diagnosed with either bulimia nervosa or anorexia nervosa or was deemed obese based on the Body Mass Index defin ition for obesity. All had sought and completed tre atment on at least one occasion. H owever none were able to remain in recovery and had returned to overeating, binging/purging, or restricting food intake. Fifteen of the maladaptive schema categories de veloped by

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7 Young et al., (2003) were identified through conversation with the participants including but not limited to statements associated with mistrust/abuse emotional deprivation, defectiveness/shame, failure and social isolation This study was l imited by the number of participants. Increasi ng the size of the study within the boundaries of a collective case study may provide further information a nd the ability to cross analyze the data collected Through the participants own voices t he results may provi de better insight into the development of more successful treatment protocol s r esult ing in a longer and more satisfying recovery. Research Questions The following questions will guide this inquiry: What maladaptive schemas are associated with the development of anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity in adult females? What maladaptive schemas are held in common by these three types of disordered eating ? Assumptions of the Study The primary assumption guid ing this study is that m aladaptiv e s c hema, beyond body shape, weight and diet, contribute to the in ability to sustain long term recovery for persons with disordered eating, and that e ffective long term recovery is dependent upon the identification and trea tment of these mal adaptive schema s Another assumption is that participants will express statemen ts associated with the categories of maladaptive schema developed by Young et al., (2003) Based on the pilot study it would be anticipated that all of the participants, regardless of their disorder, would express statements associated with mistrust/abuse, emotional deprivation, defectiven e ss/shame, dependence/ incompetence, failure, insufficient self control/self discipline, self sacrifice,

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8 approval seeking/ recognition seeking and unrelenting standards. A further assumption would be that this study will confirm that the compulsive overeaters resulting in obesity and the participants diagnosed with bulimia will express statements associated with abandonment; and the participants diagnosed with bulimia and anorexia will express statements associated with social isolation, enmeshment/undeveloped self and subjugation. The final assumption guiding the study is that the compulsive overeater and the participant s diagnosed with anorexia will make statements associate d with emotional inhibition. Conceptual Framework The conceptual framework presented in Figure 1 demonstrates the relationship of maladaptive schema to compulsive overeating resulting in obesity, anore xia nervosa and bulimia nervosa Figure 1 Relationship among maladaptive schema and disordered eating Maladaptive Schema Obesity Anorex ia Nervosa Bulimia Nervosa

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9 ry origin of maladaptive schema (Young et al., 2003, p. 10). The schema that develop earliest in life tend to be the strongest. When a maladaptive schema is activated by some situation that a person finds themselves in as an adult, it usually indicates a reoccurrence of an earlier childhood event. Schemas will develop throughout life. However, those that develop later in life tend to be less pervasive and not as powerful. Behavior is not a part of the schema. Instead it is the coping mechanism that drives the behavior, and people use different coping styles to alleviate these maladaptive schema (Young et al.). Some of these behaviors may include the use of compulsive overeating, binging and purging, or restricting food in order to not feel certain emotions attached to these maladaptive schemas. Therefore, for the purposes of this study, maladaptive schema are considered to contribute to disordered eating and not the reverse. The goal of this study is to follow as many of the rules as pos sible regarding q ualitative research and the use of case studies to c ontribute new informat ion regarding the impact of maladaptive schema on the treatment of disordered eating Definitions of Major Terms Anorexia Nervosa A refusal to maintain body weight at or above a minimally normal weight resulting in the maintenance of body weight at less than 85% of the e xpected rate for age and height ( American Psychiatric Association 2000 ). Binge eating Eating wi thin a short period of time an amount of food that is considered larger than an amount the majority of people would eat in a similar amount of time and a sense of being out of control duri ng the eating episode (Americ an Psychiatric Association, 2000 ).

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10 Body Mass Index (BMI) A measure of body fat calculated by dividing weight in pounds by height in inches squared and multiplied by a conversion factor of 703 ( Center for Disease Control (CDC) retrieved 2009). BMI applies to both men and women provides a reliable indicator of body fatness for most people and is used to screen for weight categories that may lead to health problems For adults 20 years of age and older, BMI is interpreted using standard weight status categories that are the same for men and women of all ages. For adults the stand ard categorie s are as follows: a BMI below 18.5 is considered underweight, 18. 5 to 24.9 is considered normal, 25.0 29.9 is considered overweight and 30.0 and above is considered obese (CDC) Bulimia Nervosa Recurrent episodes of binge eating with inappropriate re occurring behavior to prevent weight gain including vomiting, misuse of laxatives, diuretics, enemas or other medications; fasting o r excessive exercise (Americ a n Psychiatric Association, 2000 ). Core Beliefs : Implicit priori truths that are taken for gran ted and are considered central to the organization of personality. These core beliefs are generally activated by events that happen relevant to a specific belief (Schmidt, Joiner Young & Telch, 1995). (See also Schema). Compulsive Overeating For the p urposes of this study, compulsive overeating i s characterized by uncontrollable eating and ultimately weight gain due to excessive caloric intake Compulsive overeaters generally use food to block out emotional issues. Maladaptive Schema Life events tha t have become distorted in order to maintain the validity of an early memory, emotion, cognition or bodily sensation (Young et al., 2003)

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11 Obesity A condition of abnormal or excessive fat accumulation in the fat tissues of the body caused by consuming more calories than can be expended (European Food Information Council, 2009). For the purposes of this study obesity is a label used for a range of weight due to overeating that is considered to be greater than what is generally considered to be healthy f or a given height according to the Body Mass Index (BMI) not due to illness or medical condition For example a woman who is five feet six inches tall would be considered obese if she weighed 190 pounds. It also identifies a range of weight that has be en shown to increase the likelihood of attracting certain di seases and other health problems Purge Self induced vomiting or the misuse of laxatives, diureti cs or enem as (Americ an Psychiatric Association, 2000 ) Restricting Weight loss or weight con trol by unrealistically limiting the number of calories eaten during a day, fasting or the excess use of exercise (Americ an Psychiatric Association, 2000 ) Schema a broad pervasive theme comprised of memories, emotions, cognitions, and bodily sensations developed during childhood or adolescence and elaborated on t (Young et al., 2003) (See also Core B eliefs) Limitations of the Study For the purposes of this study participants will be selected based on a diagnosis of anorexia nervosa or bulimia nervosa regardless of subtypes for a total of three participants in each category The subtype will be noted h owever the results of the data collected will not reflect the various subtypes of each disorder. The literature review ed

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12 for this study does not clear ly distinguish between the subtypes of either disorder and regularly included anorexia nervosa binge purge subtype in studies with participants diagnosed with bulimia binge purge subtype. This may suggest that there are no clear differences among the subtypes of the disorder s regarding maladaptive schema. This may p rove to be a limitation of this study if clear differences between subtypes and maladaptive schema do ap pear. This study may also be limited by the level of treatment or recovery of the participants. The research is dependent upon the reporting ability of each of the participants and their ability to honestly discuss their thoughts and feelings regarding t he ir eating disorder, family systems their treatment and recovery. Another limitation may be the participant s ability to consistently and honestly journal t heir eating habits and emotions associated with food by under or over reporting behavioral sympt oms. Summary This qualitative study is based on the reality that disordered eating represent s a major health problem around the world (Shiina et al., 2005) and that cognitive behavioral therapy focusing on weight, body shape and food alone is only effe ctive in approximately 50% to 60% of patients who are treated Of those women who are reported to reach recovery through treatment there is a reported relapse rate of 35% to 36% (Keel et al. 2005). Quantitative s tudies have found that maladaptive schem a, beyond body shape and weight and eating play a role in disordered eating and m ay have an impact on recovery but these studies may be limited by the design and scope of the instruments used in data collection Stake (1995) suggests that qualitative re search is used to construct a more sophisticated reality that can withstand skepticism. The use of a

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13 collective case study will add to the body of knowledge by providing meanings that people place on events in their lives as they express in their own voic e s the role of maladaptive schema in disordered eating Organization of the Study This dissertati on will be organized into five chapters. Chapter 1 is an overview of the dissertation topic that is the center of this study. Chapter 2 provides the framew ork on which the study is grounded and the literature review. Chapter 3 provides a description of the method used for the study and a description of the sample population. Chapter 4 will provide the results of the study and Chapter 5 will include the di scussion of the study including theoretical and practical implications.

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14 Chapter 2 Literature Review This chapter describes previous research regarding maladaptive schema in relationship to anorexia nervosa, bulimia nervosa, binge eating, and compulsiv e overeating resulting in obesity. It is divided into three sections: 1. A description of anorexia nervosa and related literature 2. A description of compulsive overeating resulting in obesity and related literature. 3. A description of bulimia nervosa and binge eating and related literature Anorexia Nervosa Anorexia is characterized by limited food intake, the misuse of laxatives, and extreme weight loss (Fairburn, Shafran, & Cooper, 1998). Individuals with this disorder fear gaining weight or becoming fat (Amer ican Psychiatric Association, 2000) It is a life threatening condition that carries a significant risk of death due to cardiac complications, including electrocardiography abnormalities, reduced heart rate, metabolic and electrolyte disturbances, blood p ressure changes, and mitral valve prolapsed (Katzman, 2005). There are several points of view regarding the scope of factors involved in the disorder including socio cultural, family, cognitive behavioral and neurobiological issues (Fairburn et al. ). An orexia includes two subtypes: (1) restricting

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15 subtype, characterized by re striction of the amount of food sometimes to the point of completely eliminating food from a daily routine, and (2) binge purge subtype which includes the person actively engaging in the use of self induced vomiting, laxatives, diuretics or enemas in order to restrict calorie intake ( Americ an Psychiatric Association 2000). Only one study examined the relationship of obsessiveness, depende ncy, hostility directed at self and assertiv ene ss in undergraduate women as it relate d to attitudes and behaviors of anorexia (Rogers and Petrie, 1996) The participants included 196 undergraduate women all taking psychology classes at one university. The mean age was 21 years of age and the break down of ethnicity included 83% Caucasian/non Hispanic, 6% Hispanic, 5% African American, 3% Asian American and 2% Native American Indian. Each participant was asked to fill out a total of five self reporting questionnaires. The Eating Attitudes Test (EAT ; Garner & Garfinkle, 1979 as cited in Rogers & Petrie) was used to assess symptoms of anorexia in the participants. The Leyton Obsessional Inventory Questionnaire (LOI Q; Snowdon, 1980 a s cited in Rogers & Petrie ) was also administered This is a forced choice questionnaire concerning chronic thoughts about obsessive symptoms and traits of rigidity, perfectionism, and excessive attention to detail. The third measure used was the Interpersonal Depende ncy Inventory (IDI; Hirschfield et al., 1977 as cited in Rogers & Petrie). This measure was used to assess thoughts, feelings, beliefs and behaviors associated with the needs and values of other people important in the life. Fourth, t he Hostility and Direction of Hostility Questionnaire (Cain e, Foulds & Hope, 1967 as cited in Rogers & Petrie) uses 51 items selected from the Minnesota Multiphasic Personality Inventory which measure s the

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16 degree and direction of hostility. Lastly, each participant was asked to take the Rathus Assertiveness Sche dule (RAS; Rathus, 1973 as cited in Rogers & Petrie). This schedule measures the extent to which the participants express ed assertive behaviors in various simulated social situations. The students were all tested at the same time i n a group session where all five tests were administered back to back The results indicate d that higher EAT scores were related to obsessive traits ( r = .42) and a higher emotional reliance on other people ( r = .35) both of which are essential features in the diagnosis of anore xia nervosa. There did not appear to be a correlation between anorexic symptoms and self directed hostility ( r = .18) There also appeared to be no relationship between symptoms of anorexia and assertiveness ( r = .09) Earlier studies had found that an orexics and bulimics had difficulty in asserting themselves and indicated being hostile toward themselves The authors suggested that the lack of a relationship in this study may be due to the fact that none of the participants had been diagnosed or treat ed for anorexia prior to this study. They also suggest ed that the women may know how to answer the questions in an assertive manner when responding to an assertiveness questionnaire but may no t actually respond assertively when confr onted in real life si tuations. Limitations reported in the study included the reliance on self report measures and the number and amoun t of time given to fill out all five measures. Another limitation was that none of the women involved in this study had been previously diagn osed with an eating disorder and the EAT only reports that there is a propensity for the test t aker to have an eating disorder. The EAT does not provide a diagnosis. The authors were also concerned with the possibility that some participants may have und er or over reported

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17 symptoms. Lastly the sample was drawn from a single source which restricts the gene ralizability of the results. There appear to be limited studies specific to anorexia restrictive type involving core beliefs beyond weight and body sha pe. Studies regarding bulimia also included anorexia, particularly the binge purge subtype. Those studies are reported in t he section on bulimia nervosa. Compulsive Overeating Resulting in Obesity Childhood and adult obesity is considered a major health p roblem particularly in the United States ( Cooper & Fairburn, 2001 ; Flegal, Carroll, Kuczmarski & Johnson, 1998 ) On a daily basis one can find report s, articles and stories in the media r egarding the growing concerns for obesity in the U.S. and the heal th risks involved in being overweight or obese P eople with weight problems are more likely to have any number of health issues including heart disease, hypertension, stroke, diabetes, osteoarthritis, and some forms of cancer ( Bray, Bouchard & James, 1998 as cited in Cooper & Fairburn) Approximately 50% of the population in the United States is overweight and 20% are considered to be extremely overweight or obese (Flegal et al. 1998 ; Vissch er & Seidell, 2001). There are numerous popular diets and weight loss programs that promise to provide a solution to being overweight however none appear to provide a long term solution to the problem. Research indicates that people who are obese can lose weight. H oweve r, they almost always regain it: o ne half regain the weight lost within the first year and approximately 80% regain all the weight or exceed their former weight within

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18 five years (Byrne, Cooper & Fairburn, 2003). If simply losing the weight was the issue then maintaining the loss would not be a prob lem. For the purposes of this study c ompulsive overeating resulting in o besity is the condition of elevated fat masses in the body caused when the use of food and eating are the result of emotions rather than due to physical feelings of hunger. The unde rlying cause is a positive energy balance that leads to weight gain because the number of calories consumed exceeds the number of calories expended ( E uropean F ood I nformation C ouncil 2009 ). While there can be medical reasons for obesity such as thyroid disease, for the purposes of this study overeating is considered to be an emotional response to thoughts and feelings Compulsive overeaters tend to eat in an effort to control or regulate mood, or to avoid negative feelings and they have a dichotomous thinking style (Byrne, Cooper, & Fairburn, 2003). Only two studie s were found that discussed a connection between core beliefs and compulsive overeating resulting in obesity. vanH answijck de Jonge et al. (2003) investigated sexual abuse and negative core beliefs associated in morbidly obese adults The hypothesis was that adults who were victims of childhood sexual abuse would have a higher Body Mass Index (BMI) and less weight fluctuation than obese individuals who had no history of sexual abuse (vanHan swijck de Jonge et al.). Participants were men (n=6) and women (n=24) who were referred for assessment as candidates for gastric bypass surgery. No other demogra phic information was provided. Each participant provided a weight history and completed two q uestionnaires that measured childhood experiences of abuse, neglect, and current core beliefs T he first was the Childhood Abuse and Trauma Scale is a 38 item self report questionnaire that

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19 addresses various childhood and adolescent traumatic experiences ( Saunders & Becker Lausen, 1995 as cited in vanHanswijck de Jonge et al.). A review of the responses indicated that 10 of the 30 participa nt s reported a history of abuse. The second measure was the Young Schema Questionnaire S hort form (YSQ S) Young (19 98 as cited in vanHanswijck de Jonge et al., 2003 ) developed the YSQ as a measure to identify maladaptive schema. The original test contains 205 items and 18 scales and is now referred to as the YSQ L. The short version includes 75 items and 15 of the or iginal 18 scales ( vanHanswijck de Jonge et al. ). The results indicated that morbidly obese patients who reported being sexually mol ested had significantly higher scores on the YSQ S scales of defectiveness/shame ( r = .47 ) social isolation ( r = .74 ) vulne rability to harm ( r = .45 ) and subjugation ( r = .60). For the nonabused group only dependence/ incompetence (r= .43 ), and entitlement beliefs (r= .55 ) appeared to be associated with a high BMI but not considered morbidly obese Those with a high BMI and reporting sexual abuse showed a wider range of negative core beliefs relating to emotional deprivation ( r = .74), abandonment ( r = .67), social isolation ( r = .74), subjugation ( r = .60 ), and unrelenting standards ( r = .82 ). The researchers concluded that the level of weight fluctuation between the abused and nonabused groups was minimal; however, the abused group had more negative core beliefs. Women with a higher BMI had stronger maladaptive beliefs regarding emotional deprivation (r = .74) concerns fo r abandonment (r = .67) social isolation (r = .74) unrelenting standards (r = .82), and subjugation (r = .60) Also, the degree to which their weight had changed during adulthood was positively associated with issues of abandonment and social isolation (va nHanswijck de Jonge et al. ). The use of a small

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20 sample size, and gathering participants from one source were both suggested limitations of this study. It was also noted that men and women tended to react differently to sexual abuse and the inclusion of men in this study may have had a s light impact on the results. Byrne et al. (2003) used a qualitative method to explore the psychological factors involved in successful or unsuccessful weight maintenance in women with a history of obesity. The main pur pose of the study was to identify factors that differentiate participants who could maintain a weight loss and those who regained the weight. The 76 female participants ranged in age from 20 to 60 years and were recruited through an advertisement in a loc al newspaper. The women were divided into three groups, maintainers ( n=28 ) regainers (n=28) and stable healthy weight ( n=20 ) The maintainers included women who had successfully lost 10% of their initial body weight and had maintained the weight loss f or at least one year. The regainers were women who had lost 10% of their initial body weight but had not maintained the loss, and the stable healthy weight group was women who had no history of obesity and had maintained a healthy weight for at least two years. The stu dy was done in two phases. In phase one in depth interview s with 2 0 women from each group were held The entire text of each interview was reviewed and coded in to a total of 64 possible categories and statements that represented similar th emes. For example if the participant made a comment about body i mage it was coded under that category The mean intercoder reliability coefficient across all the interviews was r = 0.75, P > 0.01 (Byrne et al., 2003). Phase two included two separate gro up interviews with eight women, four from the maintainers and four from the regainers groups who had not participated in an

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21 individual session. The second part of the project was intended to identify whether the factors identified in part one could be sup ported by a new group of participants using a different met hod to collect data. A vignette was presented to each group r egarding Mrs. Brown, a regainer. The story was read to the participants and then a series of questions followed asking the participant s if they agreed that Mrs. Brown would have acted in the way described in the vignette D iscussion between the group members was encouraged and a researcher kept track of how many participants agreed or disagreed with Mrs. s from each group were then coded to determine if the hypothesis from phase one was supported. Factors that generated less than a 50% agreement were discounted. The factors that differentiated maintainers from regainers fell into three broad categor ies : b ehavioral, cognitive and a ffective factors (Byrne et al 2003 ). Behaviorally 87% of maintainers reported sticking to a low fat diet versus 0% of regainers. Maintainers were able to be consistent with an exercise regime (73%) while only 7% of regainers c ontinued to exercise regularly. Lastly, maintainers frequently monitored their weight (73%) whereas only 40% of the regainers continued to monitor weight Cognitively, 87% of the maintainers reported satisfac tion from their weight loss and only 40% of r eg ainers reported satisfaction. Regainers placed a higher value on weight and shape in reference to self worth (73%) and were more critical about their lack of weight loss or lack of achieving a specific goal (40%) Maintainers placed a lower value on weig ht, shape and self worth (13%). Even though both maintainers and regainers reported having serious life events occur since they lost weight, the maintainers did not use food to c ope with stressful events. Ninety one percent of the regainers

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22 reported tha t they were more likely to use food under adverse circumstances to r educe stress or anxiety. The results suggest that issues of obesity are not exclusively biological in nature, and psychological factors may play a role ( Byrne et al. 2003 ). The strengths of this study were the use of two different methods to collect data and multi coding using more than one indepe ndent researcher Limitations of the study included potential subject recall bias indicating that the regainers may have been more likely to ev aluate self worth in terms of weight and shape simply because of their lack of success with weight loss (Byrne et al.). Bulimia Nervosa Bulimia nervosa was first identified as a distinct disorder by Gerald Russell, & Wei ner, 2004). Bulimia nervosa is characterized by gorging oneself on enormous amounts of food and then vomiting in an effort to reduce stress and anxiety (Anderson & Maloney, 2001). Buli mia has two subtypes, (1) t he purging type involves the person regular ly engaging in self induced vomiting or misuse of laxatives, diuretics or enemas and (2) non purging subtype involves the person using other inappropriate compensatory behaviors such as fasting or excessive exercise but does not regularly engage in self induced vomiting or the misuse of laxatives, diuretics or enemas (American Psychiatric Association, 2000 ). Both subtypes can resul t in serious medical problems. Medical complications include renal and electrolyte abnormities such as a loss of potassium d ue to chronic vomiting, diuretic use, and laxative abuse (Mehler et al.). After bulimic individuals binge on food, they will immediately vomit T he gastric juices used

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23 in the stomach for the digestion are eliminated along with the foo d which will cause e rosion of the enamel on the teeth. Esophageal rupture, although considered rare, is a life threatening complication for bulimic individuals. Other concerns are chronic constipation or flaccid colon causing a loss of control over bowel function. Bulimic individuals also may develop cardiac complications including mitral valve prolapsed (Mehler et al.). Bulimia appears to be the most researched of the eating disorders in reference to maladaptive schemas. Beam, Servaty Seib, & Mathews ( 2004) hypothesized t hat college age women who experienced a loss of a parent through divorce or death were more lik ely to have an eating disorder than peers who had not experienced the same loss. Using a quantitative study, 48 women from one college were randomly selected wh o either had divorced parents (N= 16) had experienced the death of a parent (N=16), or were from intact families (N=16) The participants ranged in age from 18 to 24 years. No other demographic information was reported. Two quantitative instrum ents were u sed. The Mizes Anorec tic Cognitions Scale (MAC) is a 33 item questionnaire with a five point scale that measures cognitions associated with anorexia nervosa (Mizes & Klesges, 1989 as cited in Beam, et al.). The Bulimia Test Revised (BULI T R) contains 36 m ultiple choice items that measure symptoms and behaviors associ ated with bulimia nervosa and are considered highly sensitive in identif ying bulimia nervosa in college aged women (Thelen, Farmer, Wonderlich, & Smith, 1991 as cited in Beam et al.). To asses s differences in eating patterns among the three groups a single factor between subject multivariate analysis of variance was conducted, F (4, 88) = 2.85, p < .05 using membership as the quasi independent variable and the MAC and BULIT R scores as the

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24 dep endent variables. The univariate main effect for the MAC was significant F (2, 45) = 3.80, p = .05 (two ta iled). A Tukey post hoc analysi s indicated that participants who had experienced the loss of a parent through death ( M = 103.38, SD = 12.90) had sig nificantly higher scores than those who had experienced the loss of a parent through divorce ( M = 89.38, SD = 14.69). Researchers reported no significant differences regarding bulimic related behaviors among the groups. The results of the MAC indicated th at students who had lost a parent through death scored higher than those experiencing a loss through divorce, or those with an intact family. It was suggested that students who experienced the loss of a parent were more at risk for developing anorexia tha n b ulimia (Beam, et al. 2004 ) There was no significance to the scores of students with divorced parents or students with intact family systems One possible explanation is that divorce is so commonplace in our society that children and adolescents tend to consider a div orced family as normal (Beam et al. 2004 ). It is also possible that because children of divorce generally sti ll spend time with both parents they do not experience the loss in the same way as those children who have lost a parent due to death. Limitations include d not addressing possible confounding variables such as socio economic status, social support systems, emotional difficulties, age of loss and the quality o f the child parent relationship all of which may play a part in how some on e recovers or copes with loss. Leung et al. (2000) investigated the role of core beliefs in the treatment of bulimia nervosa. The study included four groups of 20 adult females diagnosed with bulimia nervosa Each group received a 12 week program of c ognitive behavioral therapy focused on beliefs regarding eating, body shape and weight. T wo questionnaires were

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25 administered pre and post treatment, the BU LI T R and the MAC The YSQ L was administered only pretreatment The BULIT R, measures bulimic sy mptoms and the frequency of binge eating, purging, and weight fluctuations. Higher scores on the BULIT R indicate higher levels of bulimic psychopat hology The MAC measures cognitions associated with anorexic and bulimic behaviors. High scores on the MA C indicate maladaptive cognitions in self esteem, self control, and approval from others (Leung et al.). Each participant also kept a log of their binge eating and purging activities throughout treatment. There was a significant link between social undesi rability and bulimic behaviors ( F = 70.7, p < 0.0001). The overall association of emotional deprivation beliefs and pretreatment MAC s cores was significant (F = 16.1, p < 0.0001). The overall pairs of variables with BULIT R scores were also significant i n all cases (F > 2.54, p < 0.05 ). Multiple regression analyses were used to identify the most parsimonious set of core beliefs that would predict change in bulimic attitudes. The first regression showed changes in the BULIT R predicted by the YSQ L scal e scores and pretreatm ent pathology (overall F = 4.62, p < 0.02; explained variance = 43%). The results indicated that participants with more maladaptive core beliefs were less successful in treatment. D efectiveness/shame, isolation and social undesirab ility were considered high predictors of a failure to stop or even reduce vomiting in bulimic pa rticipants. The study concluded that fo r some individuals the existing model of cognitive behavioral therapy could be more effective if it included more core beliefs other than those associated with food, body shape, and weight (Leung et al. 2000 ).

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26 Jones, Harris, & Leung (2005) provided an exploratory study to investigate whether women in recovery from an eating disorder maintain different patterns and levels of core beliefs than women who are currently suffering from an eating disorder. This study investigated w hether specific core beliefs were particularly related to eating disor dered behaviors and attitudes. Surveys were sent to members of the Eating Dis orders Association. All those included in the study reported that they were in recovery or currently suffering with an eating disor d er. Each participant completed the YSQ S ( Young, 1998 as cited in Jones et al ) and the Eating Disorders Inventory ( EDI ; G ardner, Olmstead & Polivy, 1998 as cited in Jones et al ). Of the 180 packets that were sent out, 95 were returned completed and useable. Th ese results were divided into two groups: those who stated they were currently struggling with an eating disorde r ( N=66), and those who indicated they were in recovery (N =29). There was also a control group (N=50) of women who denied ever having an eating disorder. A significant effect across groups on the EDI subscale scores ( F = 38.98 p < 0.001) was found The groups dif fered on all four EDI subscales: drive for thinness ( F = 46.71, p < 0.0001), bulimia ( F (2, 142) = 13.54, p < 0.001 ) ; body dissatisfaction ( F = 19.60, p < 0.001); and EDI total ( F = 68.87, p < 0.00 1). The results indicated that women currently s truggling with an eating disorder showed more pathological scores on the EDI and women who reported being in recovery showed more pathological scores on the drive for thinness scale. Across groups there was a significant overall effect on the subscales o f the YSQ S ( F = 12.98, p < 0.001) and the individual effects showed d ifferences on 13 of 15 scales.

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27 W omen who admitted to currently struggling with an eating disorder scored significantly higher than either women in recovery or a control group on all cor e belief scales except for emotional deprivation, abandonm ent, and self sacrifice Women in recovery and the control group showed no difference in their levels on the su bscales Women in recovery showed lower scores on mistrust/abuse, social isolation, d efectiveness/shame, failure to achieve, and vulnerability to harm than women with a current eating disorder but the ir scores were still significantly higher than those in the control group. The study concluded that women who believe they are in recovery still have elevated scores on drive for thinness and eating psych o pathology confirming previous studies that indicate that eating and weight concerns still persist, even in recovery (Srinivasagan et al., 1995; Stein et al., 2002 as cited in Jones et al., 2 005). Also, women within the group who were currently struggling with bulimic behaviors had more beliefs about abandonment and vulnerability to harm than women who described themselves as having anorexic behaviors. The study does show that women who appe ar to be in recovery retain negative core beliefs at a lower level than those stil l struggling with the disorder This may make them vulnerable to relapse. A s tudy on perfectionism and eating disorders was contributed by Joiner et al., (1997). The purpos e of this study was to show that bulimic symptoms and perfectionism requesting demographic information including height and weight were randomly distributed at Boston Universi ty. Along with the demographic information the participants were asked to complete the perfectionism and bulimia subscales from the EDI ( Garner, Olmsteac & Polivy, 1983 as cited in Joiner et al ). Of the 800 surveys that

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28 were sent to a randomly selected sample of women, 435 were returned. The EDI B ulimia subscale correlated strongly with the diagnostic variable ( r = .56, p < .001) and with perceived weight status ( r = .49, p > .005) The EDI Bulimia subscale correlated strongly with the diagnostic variab le ( r = .56, p < .001) with perceived weight status ( r = .49, p < .001), and with Body Mass Index ( r = .35, p < .001). The results indicated that those who were diagnosed with bulimia on the E DI and saw themselves as overweight were more likely to score h i gh on the perfectionism scale. To test predictions regarding the interaction between perfectionism and perceived weight status a set wise hierarchical multiple regression/corre lation was conducted. The EDI B ulimia subscale scores were used as the depend ent variable. The perfectionism subscales and a dichotomous variable regarding perceived weight (1= do not feel overweight and 2 = feel overweight) were used in a regression equation simultaneously as a set, followed by the perfectionism and perceived wei ght status interaction term. The result s indicated that perfectionism is weakly related to bulimic symptoms ( pr = .18, t (432) = 3.75, p <.05); and perceived weight status provided a stronger relationship ( pr = .48, t (432) = 11.42, p < .05). Perfectioni sm and perceived weight status interaction served as a significant predictor of EDI bulimia scale scores ( pr = .12, t (431) = 2.47, p < .05.). Results from this study indicate that perfectionism is related to bulimic symptoms particularly when the particip ants believed they were not at the perceived ideal weight. One reported l i mitation of the study was the 54% return rate on the questionnaires which may suggest a biased response. It was also reported that because the participants were all undergraduate w omen from one university the results may not generalize to other

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29 populations. This study focused on perfectionism as it relates to body image and symptoms of bulimia. It did not address other maladaptive thoughts which may lead to perfectionism or how p erfectionism may otherwise affect bulimic behavior. This may limit it s use in identifying better treatment protocols regarding maladaptive schema s ass ociated with eating disorders. Glenn Waller participated in or has led several studies regarding the effe cts of core beliefs on the treatment of eating disorders. Waller, Ohanian, Meyer, & Os man, (1999) addressed the issue of core beliefs and the effect on binge purge behaviors in bulimic women. The questio ns addressed in this study were: (1) do different e ating disorders (e.g., bulimia nervosa, anorexia nervosa binge purge subtype and binge eating) show dif ferent patterns of core beliefs relative to each other and to a comparison group of women; and (2) are there links between core beliefs and the severity of bulimic symptom ology (Waller et al.)? The YSQ L was used excluding the scales that focused on food, shape, and weight sin ce these three core beliefs are currently being addressed within treatment The study included 50 women diagnosed with bulimia ner vosa (N=28) anorexia nervosa binge/purge subtype (N 12) and binge eating disorders (N =10) The breakdown a lso included a comparison group of non clinical women (N=50; Waller et al.). The results of the MANOVA show a clear difference across groups ( F = 2 .21; p < 001). Individual effects showed differences between the groups o n 15 of the 16 YSQ L subscales The comparison group had lower scores on the core beliefs than at least one of the bulimia groups except for the subscale of entitlement which show e d no significant difference. Multiple regressions were performed to predict levels of binging and vomiting among the

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30 bulimic group. Only 15 of the subscales were used as independent variables, excluding social undesir ability. Bulimic behavior was used a s the dependent variable. The YSQ L subscales together were able to reliably predict binge behavior ( F =2.43; p < .02, explained variance = 32.4%), but on the individual scales the only significant predictor was emotional inhibition ( t = 3.46, p < .001). The frequency of vomiting was also reliably predicted ( F = 2.88, p < .03, explained variance =30.0%) but the only significant predictor was defectiveness/shame ( t = 2.09, p < .05). The research suggests that core beliefs can differentiate those with bulim ia nervosa and may predict binging and vomiting behaviors The results suggest that binging and purging are related to reducing the ability to experience emotions particularly those associated with shame and defectiveness. V omiting is used to lessen awar eness of negative feelings and binging is used to try and regulate function. The findings suggest the importance of considering the inclusion of negative core beliefs in the treatment of eating disorders (Waller et al. 1999 ). A l imitation of this study was the use of small and uneven sample sizes which may interfere with generalization of the results Waller, Dickson & Ohanian (2002) compared the YSQ with the Eating Disorder Inventory (EDI 2 ; Garner, 1991 ) to establish which core beliefs are associated with ego dysfunction characteristics and unhealthy attitudes toward eating. This study involved women diagnosed with bulimia nervosa ( N=45) women with anorexia nervosa binge purge subtype (N=17) and women diagnosed with a binge eating disorder (N=13) The study hypothesized that the unhealthy core beliefs of poor self esteem, problematic social relationships, maturity fears, perfectionism, self denial, poor interceptive awareness, a nd

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31 poor impulse control are associated with the levels of predisposing factors to bulimic attitudes. A Product Moment Correlation was used between the scales on the YSQ and eating related scales of the EDI 2 The results indicated that restrictive eating was associated with the perception of dependence ( r = .35 P < .01 ) and an inability to express emotions ( r = .43 P < .01) Women who displayed more bulimic attitudes perceived themselves as socially different ( r = .35, P < .01) deprived of emotional support ( r = .36, P < .01) and as having low self control ( r = .49, P < .01) When these results were compared to the EDI 2 there appeared to be no association between ego dysfunction and beliefs about dependence and incompetence. However, emotional inhibition was associated with characteristics of ego dysfunctio n (Waller et al. 2002 ). The research concluded that core beliefs beyond weight, body shape, and eating are central triggers for eating disturbances and therefore should be included in treatment programs A limitation of this study is the use of small an d uneven sample size s It was suggested that the study should be re plicated using larger sample sizes (Waller et al.) In a study focusing on binge eating, Waller (2002) hypothesized that core beliefs in individuals diagnosed with a binge eating disorder would differ from a nonclinical group, but that their beliefs would be less pathological than individuals diagnosed with bulimia nervosa. This is the first study where Waller utilized groups of equal size, age, and weight levels. The groups consisted of women diagnosed with a binge eating disorder (N=25) bulimia nervosa (N=25) and a control group of nonclinical women (N=25) All the individuals involved in this study completed the short version of the YSQ. The scales of the YSQ S were compared using a multivariate analysis of variance,

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32 with a conservative alpha level ( p < 0.003) to reduce Type I errors. Post hoc pair wise Tukey tests were performed to determine the source of any differences among the groups on individual scales of the YSQ S. The over all effect of the MANOVA showed significance (F [32,114] = 6.26, p < 0.001). The two clinical groups showed higher scores than the nonclinical women o n 10 of the 15 YSQ S subscales. H owever, only three subscales showed significant differences between the clinical groups. The binge eating group had more pathological core beliefs than the participants diagnosed with bulimia. Discriminate function al analysis showed that two functions could distinguish the three groups reliably (F [4 70 ] > 6.40, p< 0.001 in all cases). This included positive loadings for the scales of emotional inhibitio n, dependence/incompetence, abandonment and a negative loading for self sacrifice. The author concluded that the binge eating disordered group was characterized by more pat hological core beliefs than was the control group. However, the pathology of the core beliefs between the binge eating group and the bulimic group showed similar levels but differed in the nature of the beliefs. For example, the binge eating group had ne gative beliefs about their ability to experience emotions, to function independently, and a need to sacrifice self for others, but had lesser concerns regarding the likelihood of being abandoned than did the bulimic group. This would suggest from a treatm ent perspective that binge eatin g disorder and bulimia groups would benefit from schema focused therapy Waller, Meyer & Ohanian (2001) compared the use of the long and short forms of the Young Schema Questionnaire (YSQ) to identify core beliefs in bulim ic women. The long form of the YSQ includes 205 items and takes time to fill out. The shorter

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33 version is only 75 questions. The purpose of the study was to determine if the short version is as affective in identifying maladaptive schema as the longer ve rsion. The participants included women diagnosed with bulimia nervosa (N=60) and a control group of women with no clinical diagnosis (N=60) They were all asked to take the long version of the YS Q. For the purpose of this study the 75 questions from t he short version were extracted from the long version so that the participants only took the test one time. The comparison of scores on the long and short version of the YSQ showed that the comparison group had similar total scores but differed on six of the 15 individual scales including functional dependence, subjugation, self sacrifice, social isolation, unrelenting standards and vulnerability to harm ( t > 2.80, p < .01 in all cases). The bulimic group showed no differences on total scores but differ ed on five of the individual scales including functional dependence, insufficient self control, unrelenting standards, self sacrifice, and entitlement ( t > 2.20, p < .05, in all cases). The correlations of the overall scales for the clinical comparison of all groups was r = .98, and r = .93 and the correlation between forms was r = .84 ( p > .001) which would suggest that removing items from the long version has no real effect on the central tendency of the scores (Waller et al. ). The results suggest that t he YSQ S provides practical advantages because of its length and that it showed similar levels of internal consistency to the long version of the test. The authors reported some differences in the scores from both versions but indicated that it was not e nough to make a difference in the results. It was re commended a s a reliable instrument for diagnostic purposes but recommended that a therapist might want to consider the longer versi on for detailed information regarding beliefs that make

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34 up a specific sc hema. Limitations to this study include the use of the YSQ L only and then adjusting it by removing questions that were not on the YSQ S. It is suggested that another test should be run actually using both versions of the test. Last ly it should be dete rmined whether or not both versions of the test are comparable among different clinical groups and across genders. Thi s would make the YSQ very useful as a research tool to assess core beliefs and their relationsh ip to psychopathology (Waller et al., 2001 ). Dingemans, Spinhoven & v an Furth (2006 ) expanded on earlier studies concerning the relationship of maladaptive core beliefs and the symptoms of eating disorders in an effort to tie the occurrence of specific core beliefs to specific eating disordered b ehaviors such as vomiting, binging, and misuse of laxatives. The participants included women (N=100) and men (N=6) diagnosed with an eating disorder and a control group of healthy females (N=27) The participants were grouped according to a DSM IV TR (A merican Psychia tric Association, 2000) diagnosis for Anorexia Nervosa (N=16), Anorexia Nervosa Binge Purge Subtype ( N = 31), Bulimia Nervosa ( N =23), Binge Eating ( N =36) and a c ontrol group ( N =27). Each participant completed the YSQ and the Bulimic Investig atory Test Edinburgh (BITE) a 33 item self report questionnaire that assesses the presence and severity of bulimic symptoms (Henderson & Freeman, as cited in Dingeman s et al. 2006). Each participant also participated i n a semi structured interview. A si gnificant overall difference was found o n the YSQ higher factors (ANOVA, p < showed that the participants with an eating disorder showed significantly more pathological core beliefs than the control group. They also found that patients with a

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35 b inge e ating d isorder showed significantly fewer maladaptive core beliefs than patients with a norexia n ervosa, b inge p urge subtype. Through the interview process a significant negativ e correlation was found between Body Mass Index (BMI) and maladaptive core beliefs and this finding was used as a covariate in the study. For the purposes of this study into four higher order factors based o n a previous study by Lee, Taylor & D unn (1999 as cited in Dingemans et al. 2006 ). The four higher or der factors and the maladaptive schema whi ch were included in each are: (a) d isconnection, including abandonment/instability, defectiveness/shame, emo t ional deprivation, mistrust/ab use, social isolatio n and emotional constriction; (b) i mpaired autonomy, including dependence /incompetence, vulnerability to harm, enmeshment, failure, subjugation, insufficient self control; (c ) i mpaired limits, including en titlement/grandiosity and fear of loss; and (d ) o ver control, including self sacrifice a nd hypercriticalness ( Dingemans et al.) A post hoc Tukey test indicated that a low BMI was associated with more maladaptive core beliefs on three of the four higher ord er factors : disconnection ( r = 0.30 p < 0.001), impaired autonomy ( r = 0.29, p < 0.01), and over control ( r = 0.31; p < 0.01). N o significant correlations were noted between frequency of binge eating and any of the four factors, however significant corr elations were found between frequency of vomiting and disconnection (r =.24, p < .05), impaired autonomy ( r = 26, p < .05) and impaired limits ( r =.27, p < .05). There were also significant correlations between laxative use and disconnection ( r = 36, p < 0.01), impaired autonomy ( r = .36, p < 0.01), and impaired limits ( r =.32, p < 0.01) and fasting and disconnection ( r = .30, p < 0.01), impaired autonomy ( r = .28, p < 0.01) and impaired limits ( r = .27, p < 0.01).

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36 The researchers concluded that those i ndividuals with an eating disorder showed unhealthier core beliefs than did the control group. Anorexics and bulimics did not differ in the degree of unhealthy core beliefs, but those with a binge eating disorder scored much more like bulimics than anorex ics. The results also indicated that those individuals who had inappropriate compensatory behaviors such as vomiting were more likely to exh ibit maladaptive core beliefs ( Dingemans et al. 2006 ), suggesting that purging and fasting behaviors may not be u sed just to control weight. They may also serve the purpose of providing a sense of empowerment, rebellion, punishment or self defeating behaviors. Also, it was suggested that individuals who binge and purge find a sense of relief, relaxation, and/or n um bness after vomiting ( Dingemans et al.). Limitations of the study included unequal and small sample sizes T he study was based on cross sectional data which may not allow for statements about the c ausal relationships between core beliefs and patients with anorexia and binge eating disorders. Another possible limitation to the study may be the inclusion of a small number of men as van Hanswijck de Jonge et al. (2003) suggested men and women may react differently regarding events and core beliefs which may impact the results. maladaptive schema into four categories this study also did not identify the specific core beliefs re lated to each eating disorder. Cooper, Rose and Turner (2006) used a variety of tests to identify the specific core beliefs and schema that are associated with eating disorders but not associated with depression. The study included 52 adolescent females, recruited through high schools who scored 30 or more on the Eating Aptitude Test (EAT Gardner & Garfinkle 19 79 as cited in Cooper et al. ) A scor e of 30 or higher on the EAT is considered the clinical

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37 cutoff to diagnose an eating disorder. The students were all volunteers and completed the testing measures individually and anonymously. D emographic information regarding age, weight and height was collected. Each participant was asked to complete the Beck Depression Inventory (BDI: Beck & Steer, 1993 as cited in Cooper et al.), the Eating Disorder Belief Questionnaire ( EDBQ; Cooper, Cohen Tovee, Tood, Wells & Tovee, 1997 as cited in Cooper et al.) and the Young Schema Questi onnaire ( YSQ; Young 1994 as cited in Cooper et al. ). Those participants who scored hig h on the EAT scored significantly higher than the low EAT g roup on the BDI (low EAT; mean 4.56, SD = 3. 6; high EAT: mean = 20.2, SD = 10.2 ) indicating that the high EAT group showed more depressive symptoms. The high EAT group also scored significantly higher on the negative self beliefs subscale of the EDBQ, on the total YSQ and on all but one of the subs cales of the YSQ. The number of clinically significant schema endorsed by the high E AT group (mean 13.8, SD = 11.8) was significantly higher than the low group (mean 3.0, SD = 3.0). Partial correlations and links to specific core beliefs and symptoms of eating disorders were found that were not explained by depression (Cooper et al.). Only three items from the YSQ were related to EAT with the BDI score partialle d out mistrust/abuse, emotional inhibition and i nsufficient self control ( p = .05 for all). C ooper et al ., (2006) conclude that this research provides a first step toward identifying specific core beliefs associated with eating disorders unrelated to depressive symptoms. Limitations of the study include d the lack of a clinical group of participan ts diagnosed with an eating disorder, and not separating participants with symptoms of

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38 anorexia versus th ose with symptoms of bulimia. A study should be considered separati ng the two eating disorders A two part study by Hayaki, Friedman, and Brownell (20 02) expanded on other investigations of the relationship of shame related specifically to bulimia nervosa. T he first study used female undergraduate students ( N =137) with mild to moderate levels of bulimic symptoms. The second study used a group of women ( N =68) who were being seen a t an outpatient eating disorder clinic. In order to test specifically for shame the study controlled for symptoms of guilt and depression both of which were considered to be possible competing predictors of binge purge behavi ors. Both groups were asked to take th e BULIT (Smith & Thelen, 1984 as cited in Hayak i et al ), the BDI (Beck Ward, Mendelson, Mock & Erbaugh 1 961 as cited in Hayaki et al.), and the Test of Self Conscious Affect ( TOSCA; Tangney, Wager & G ramzow, 1989 as cited in Hayaki et al ). Special interest was paid to the shame and guilt subscales of the T O SCA Each BMI was calculated based on a self report of height and weight Using a Pearson Product Moment Correlation it was found t hat shame was not directly correlated with age ( r = .07) or BMI ( r = .08), but did show a correlation to guilt ( r = .35, p < .0001), d epression ( r = .47, 0, p < .0001), and b ulimic symptoms ( r = .50, p < .0001). Bulimic symptoms were also significantly correlated wit h depressed mood (.42, p < .001). Hierarchical regression analyses were performed testing the contribution of age, BMI, guilt, depressed mood, and shame to the composite scores of the BULIT. The results indicated that shame uniquely predicted .12 of the variance in BULIT above all other factors A sta tistically significant increase was found ( F [1, 131] = 23.68, P < .001 ) indicating that shame is associated with bulimic symptoms when controlling for

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39 depression and guilt. T he second study f o und that sham e was significantly correlated with depression and guilt ( r = .71, P < .000 and r = 33, P < .01). An ANCOVA was performed to test differences in shame and guilt using depressed mood and guilt as covariantes. The results in dicated that the bulimic group s howed higher levels of s h ame than the nonbulimic group ( F [1, 56] = 6.76, P <. 05 ). In both the undergraduate and clinical group s shame was found to be highly correlated with bulimic symptoms, however within the clinical group ; the relationship of shame w as not independent of depressed mood and guilt. No clear explanation was offered as to why the clinical findings were unable to differentiate feelings of shame from depression except to suggest that women with higher levels of psychopathology may not asso ciate shame uniquely to their eating disorder. Limitations of this study would include a lack of diagnostic information from both groups, and unequal sample sizes It is possible that the number of self scoring instruments may be a limitation I t is uncl ear how long the participants were given to complete the battery of tests and test fatigue could alter the responses of the participants. Leung & Price (2007) compare d c ore beliefs and eating symptom ology in eating disorders, symptomatic dieters, normal d ieters and a group of comparison women. The eating disorder group was a mixed group of participants diagnosed with either anorexia nervosa ( N =16) or bulimia nervosa ( N =19) The symptomatic dieters ( N =16) showed some eating disorder behaviors similar to anorexia and/or bulimia. The normal dieters ( N =39) were a group of women who had been attempting to lose weight for at least four weeks and had no previous history of an eating disorder. The comparison group consisted of women ( N =34) who were currently n ot on a diet and had never been

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40 diagnosed with an eating disorder. They all completed the EDI ( Garner, Olmsted & Polivy, 1993 as cited in Leung & Price), the YSQ S ( Young, 1998 as cited in Leung & Price ), t he Beck Depression Inventory II ( BDI II; Beck, Steer & Brown, 1996 as cited in Leung & Price), and the Rosenberg Self Esteem Inventory (Rosenberg, 1965 as cited in Leung & Price). The Rosenberg Self Esteem Inventory uses a 10 point Likert scale where a higher score indicate s a higher level of self e steem. Normal diet ers and comparison dieters showed the least pathological scores in relationship to the other groups. The eating disordered group scored significantly higher than the symptomatic group on the subscales of e motional deprivation ( M = 3.08, SD 1.46), m istrust/abuse ( M = 3.88, SD 1.48), s ocial i solation ( M = 3.94, SD 1.436), d efectiveness/shame ( M = 3.95, SD 1.50), f ailure to achieve ( M = 3.65, SD 1.79), f unctional dependence ( M = 3.17, SD 1.50), and v ulnerability to harm ( M = 3.23, SD 1.50). A multiple A NCOVA analy ses indicated that the differences on the EDI scores among the groups remained significant after contr olling scores on the BDI and R SE ( p < 0.001 ) for drive for thinness, b ulimia and body dissatisfaction ; this suggests that eating s ymptomology was not influenced by depression or self esteem. A multiple ANCOVA was also conducted regarding core beliefs A significant difference was reported across groups on all scales even after controlling for the BDI and RSE ( p < 0.01 for self sacri fice; p < 0.001 for all other scales) suggesting that core beliefs are not significantly influenced by depression. T he results indicated that symptomatic dieters and women with eating disorders di d not differ greatly in th eir eating symptoms H owever th e women diagnosed with an eating disorder showed very different patterns o n their level of core beliefs. Women with

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41 a diagnosed eating dis order scored higher on 8 of 15 c ore beliefs identified by Young et al., (2003) The authors conclude that individual s with an eating disorder are different from symptomatic dieters. One limitation of this study is that participants with an eating disorder were consistently put together as one group rather than testing them independently based on the specific eating dis order. This study also suggests that the sample size is small and therefore the results may not generalize. Rogers & Petrie (2001) investigated psychological correlates to obsessiveness dependency, over controlled hostility, assertiveness, locus of contr ol and self esteem related to symptoms of anorexia and bulimia in a nonclinical population. Participants in this study were undergraduate women (N= 97) all taking courses at one southwestern university with a mean age of 22.17 years. ethnici ty was 72% Caucasian Non Hispanic, 10% Asian American, 7% African American, 7% Hispanic, 2% Native American and 1% other (non specified). All participants were requested to take a series of self reporting tests or questionnaires including the EAT (Garner & Garfinkle 1979 as cited in Rogers & Petrie), the Bulimia Test Revi sed (BULIT R; Thelen, Farmer, Wo nderlich, & Smi th, 1991, as cited in Rogers & Petrie), the Leyton Obsessional Inventory Questionnaire (LOI Q; Snow don, 1980 as cited in Rogers & Petrie), t he Interpersonal Depend ency Inventory (IDI; Hirschfeld et al., 1977 as cited in Rogers & Petrie), the Hostility and Direction of Hostility Questionnaire (HDHQ; Caine, Foulds & H ope, 1967 as cited in Rogers & Petrie) and the College Self Expression Scale (CSES; Galassi, DeLo, Galassi & Bast ein, 1974 as cited in Rogers & Petrie). The I DI is a 48 item inventory that measures thoughts, feelings, beliefs, and behaviors related to needs associated with person s considered to be valued by the test take r (Roge rs & Petrie). The

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42 H DH Q measures the degree and the direction of hostility. It is a 51 item true or false questionn aire based on five subscales: (a ) urge to act out hostility, ( b) criticism of others, (c ) pr ojected delusional hostility, (d) self criticism, an d (e ) guilt. The CSES measures positive feelings, negative feelings, and self denial in relationship to ass ertiveness using a five point Li kert scale (Rogers & Petrie). Regression analysis found that anorexic symptoms on the EAT were significant and the v ariables of obssessiveness accounted for 13% of the variable ( = .24, p < .05), emotional reliance added another 5% ( = .29, p < .01), and assertiveness added 3% ( = .20, p < .05). In reference to bulimic symptoms on the BULIT R the variables of self confidence accounted for an additional 14% of the variance ( = .28, p < .01), and obsessiveness added 6% ( = .28, p < .01) indicating that the best predictors of bulimia are self confidence and high levels of obsessive behavior. The findings indicate th at personality characteristics are related to symptom s of disordered eating in a non clinical sample. The authors found that symptoms of anorexia may be characterized by a dependence upon someone who is considered close and a need to deny a reliance on that person. This appears to support the idea that women diagnosed with anorexia have been encouraged to show compliance, have dependent behavior and maintain e nmeshed relationship s (Rogers & Petrie 2001). In reference to bulimia, the BULIT R scores identifi ed a lack of self confidence as the only dependent factor which coincided with the belief that b ulimics have a need to acc ommodate and please Limitations of this study included a possible bias as it relied heavily on self reporting measures. Participants may have over or under stated their symptoms in

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43 responses to each measure. The number of measures used may also result in test fatigue as the amount of time allowed for taking the tests is not reported. Also there is an issue of generalizability since t he sample was selected from only on e source. The results were not broken d own according to ethnicity. The s e may be consideration s for future studies. A pilot study by Hurley (2008 ) using a collective case study inclu ded interviews with three women diagno sed with either anorexia nervosa (N=1) bulimia nervosa (N=1) or fit the BMI chart for obesity (N=1) All three women were interviewed and tape recorded regarding their family experiences or perceptions of growing up, their thoughts and feelings regarding specific family members and information regarding their specific disorder. General demographic information was collected including date of birth, height and weight. E ach participant was asked to keep a sample food journal The sample food journal wa s provided as a means for tracking eating behaviors, binge and purge episodes and their relationship to maladaptive schemas. Once the interview was transcribed each participant was invited back to review the transcript They were allowed to add, delete or change any of the information they had provided at the recorded interview. None of the participants deleted or changed the transcribed interview. However, one participant provided more detail to some of her original responses. Once the information w as added to the transcript she was asked to review it for a second time. At this time saturation was reached as she did not add, delete or change any information provided over the course of member checking. Using maladaptive schema definitions (Young, e t al., 2003) each transcription was reviewed and coded for statement s associated with maladaptive schema

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44 Upon reviewing the coded statements it was found that there were very few maladaptive schemas that did not appear in each of the interviews. All thr ee participants made statements associated with nine categories Each of the participants expressed statements regarding mistrust/abuse emotional deprivation, defectiveness/shame, dependence/incompetence, failure, insufficient self control/self disciplin e, self sacrifice, approval seeking/recognition seeking and unrelenting standards. The participants with issues of obesity and bulimia nervosa each made statements suggesting beliefs of abandonment. Both the bulimic and the anorexic participants made s tatements regarding their struggle with social isolation, enmeshment/undeveloped self, and subjugation. The anorexic participant and the obesity participant made statements which suggest they have problems in the area of emotional inhibition. Only two ca tegories did not appear in any of the statements made by the participants, negative/pessimism or entitlement/grandiosity. Only the anorexic participant made a comment that appeared to fit the category of vulnerability to harm or illness, however, it was s ituational regarding her fears of an ex boyfriend. Each of the participants believed that they now had their eating disorder under control H owever some of their statements and the sample food journals that were returned suggested that the maladaptive sc hema continue to affect t heir ability to completely stop binging, purging, overeating or restricting. This pilot study suggests that maladaptive schema appear to play a role in anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obe sity and that at least 15 of the 18 maladaptive schema defined by Young et al., (2003) may be involved in the behaviors and beliefs that led to relapse

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45 A limitation of this study was sample size. Using one participant for each eating disorder provided c omparison between eating disorders but no comparisons within specific eating disorder A larger sample size would allow for this type of comparison. Another limitation was the limited information provided on the food journals by the participants. It ma y not have provided a clear picture of success or lack of success in recovery. Also, one participant failed to return the journal for review. Analysis of Literature Review Chapter 2 provides a re view of the literature associated w ith maladaptive schema a nd eating disorders. Based on the research there appears to be evidence that maladaptive schema beyond body shape, weight and eating play a role in disordered eating. Using a quantitative approach to the research, a variety of testing measures were use d All totaled, 16 various questionnaires and surveys associated with eating disorders, depression, assertiveness, child abuse, hostility, and self esteem were used to collect information associated with bulimia, anorexia, binge eating disorder and obesit y. At least 10 studies also compared the Young Maladaptive Schema Questionnaire with many of the aforementioned tests to identify specific maladaptive schema associated with each disorder. Several studies found positive results linking the Young et al., (2003) identified categories of maladaptive schema with disorder ed eating even though this measure was not written specifically for use with this population Leung & Price (2007), Wa ller, Ohanian et al., (1999), and Waller, Dickson & Ohanian (2002) all c oncluded that the inclusion of maladaptive schema beyond body shape, weight, and eating would provide a more effective treatment with a lower rat e of relapse. Dingemans et al. (2006) resolved that people with eating disorders had more negative core belief s than a non e ating

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46 disordered sample. Jones et al. (2005) concluded that women in recovery from disordered eating still carried more maladaptive schema although at lower levels than those who have not been in recovery. Hayaki et al. (2002) found that s hame is associated with bulimic behaviors when contro lling for depression and Cooper et al. (2006) found that maladaptive core beliefs not associated with depression were present in adolescent girls with eating disorder symptoms. The majority of studies found some maladaptive schema beyond body shape, weight and eating in women di agnosed with an eating disorder. H owever, not every study found the same schema. In studies on obesity maladaptive schema associated with defectiveness/shame, social isolatio n, vulnerability to harm and subrogation showed the highest correlations. In relationship to bulimia, anorexia and binge eating disorders 12 et al., (2003) categories were identified but not all studies identified all of the same categories For example van Hanswijck de Jonge et al (2003) found th at subjugation, social isolation, emotional deprivation, abandonment, and unrelenting standards were all h ighly correlated Jones et al. (2005) identified high scores on mistrust/abuse, social i solation, defectiveness/shame, failure to achieve and vulnerability to harm. Waller et al. (2002) found that restrictive eating was associated with dependence/incompetence, emotional deprivation, and insufficient self control. Several other studies focu sed on a specific maladaptive schema, such as perfection ism and resolved that women diagnosed with an eating disorder were more likely to score high on the perfection ism scale (Heatherton et al. 2007). Limitations of these studies included a high relian ce on self reporting measures and an undisclosed or unreported amount of time allotted for test taking was not reported.

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47 Ea ch of these measures used standardized questions with either ye s/no or some type of Li kert scale with prepared forced responses. So me of the studies used only two questionnaires, while others used as many as five or six measures. This may have lead to test fatigue T he results may not be as accurate as they could have be en by using fewer tests and/or balancing the number of measure s with the amount of time necessary to complete them without causing fatigue. Many of the studies combined several eating disorders together into one category. For example, several studies combined bulimia and anorexia binge/purge subtype into one categor y. Other studies us ed small unequal sample sizes. s (2008) pilot study provided a qualitative approach to identifying maladaptive schema associated with disordered eating This case study method offered an opportunity to associate real life events to maladaptive schema wh ich may lead to disordered eating With the use of words and phrases most often associated with maladaptive schema 15 of the 18 categories established by Young et al., (2003) were identified by at least one and in some cases all t hree of the participants. A limitation of this study was the use of one identified participant in each disordered group which did not allow for within group comparisons. The purpose of using a qualitative method in this study allowed each of the particip ants to tell her story in her own words. This allow ed the researcher to identify maladaptive schema based on each participants own stories and life events. This method is similar to conducting a psycho social evaluation in a treatment setting. The result s are instrumental in goal setting for treatment success. Further research from a qualitative perspective using a larger sample size would allow for

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48 a stronger cross analysis across eating disorders as well as an analysis from a within group perspective. Summary As seen in Chapter 2, numerous q uantitative studies have found several categories of maladaptive schema beyond body shape, weight and eating that appear to play a role in various eating disorders which may impact recovery and relapse. However, th ese studies are limited by the design and scope of the instruments used in data collection. Hurley (2008) used a qualitative method in a pilot study w hich allowed participants to describe in their own voices maladaptive schema which may have played a role in their recovery and relapse from disordered eating. The pilot study was limited by the number of participants and did not allow for an in depth analysis within or across groups. This dissertation is an expansion of the pilot case study By increasing t he number of participants in this study this researcher will be able add to the body of knowledge and provide a more in depth analysis of the role of maladaptive schema in disordered eating. Chapter 3 covers th e design and methodology for the current pr oposed collective case study. It provides a detailed explanation of the methodology to be used in this study, including a description of the participants, procedures, instrumentation and the intended analysis.

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49 Chapter 3 Design and Methodology Chapte r Two presented a literature review of previous research that provided evidence that maladaptive schema beyond body shape, weight, and eating play a role in disordered eating. The majority of studies used a quantitative approach and numerous testing instr (2003) Maladaptive Schema Questionnaire. The majority of the studies reviewed indicated that maladaptive schema beyond body shape, weight and eating play a role in disordered eating. Limitations of the majority of the studies re viewed were the high reliance on self reporting measures and the amount of time allotted for the numerous testing instruments that were sometimes required. In a et al., m aladap t ive s chema in disordered eating. H owever the limited number of participants did not provide for cross analysis or within group comparisons. The current study is an expansion of the pilot study. This study included 10 case studies and has allowed for a further comparison of information. This chapter provides a description of the current and method including a description of the participants, data collection procedures, recruitment procedure s, and th e process used to analyze the data

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50 Research Issues The purpose of this study was to further explore maladaptive schema associated with disordered eating, specifically related to anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obe sity in order to better understand treatment, recovery and relapse in disordered eating. Cognitive Behavioral Therapy focusing on body shape, weight, and eating has reported a high rate of recovery for those who complete the treatment protocol (Agras, 19 97; Anderson & Maloney, 2001) H owever there is also a reported 36% rate of relapse in persons treated for bulimia nervosa and ano rexia nervosa (Keel et al., 2005). The current treatment models generally are based on 20 sessions of group and individual therapy focusing on a cognitive behavioral approach. The high rate of relapse may be associa ted with the concept that cognitive behavioral therapy assumes patients will be able to identify and access their cognitions and emotions within 20 treatment sessi ons However the limited number of treatment sessions may have also limited the scope of treatment and therefore the focus has been limited to body shape, weight, and eating. Maladaptive schema are so much a part of who a person is that without identifyi ng and altering these schema the chances of long term recovery may be limited (Young et al., 2003). Exploration into the identification and effect of maladaptive schema associated with disordered eating may further develop and improve treatment protocols Two questions have been posed for this research. First, what maladaptive schemas may be associated with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity in adult females? Second, what maladaptive schemas do these eating disorders hold in common? Identifying the specific maladaptive schema and which are held in common may help with the development of

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51 stronger treatment protocols in the future This may help to reduce the rate of relapse and support a more satisfying rec overy. Research Design A review of the previous literature identified limitations to research using a quantitative approach including small and unequal sample sizes. The majority of these studies also used numerous testing instruments in each study which may have resulted in test fatigue by the participants. Another possible limitation included how participants were grouped according to their eating disorder. While the DSM IV TR (American Psychiatric Association, 2000) identifies two subtypes of anorexi a nervosa and two subtypes for bulimia nervosa, much of the research grouped anorexia binge purge subtype and bulimia binge purge subtype together. No current literature was found on anorexia nervosa or bulimia nervosa and maladaptive schema which identif ied differences between the subtypes. While conceptual differences could exist in subtypes of eating disorders, the purpose of the current study was to identify maladaptive schema that applied generally to each disorder regardless of subtype. A bounded c ollective case study was used to identify maladaptive schema associated with the general diagnosis of anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity. A collective case study uses several cases rather than focusing on one specific case (Stake, 1995) in order to provide compelling evidence, and make the study more robust (Yin, 2003). In this collective case study multiple individuals play ed a role. While each is defined as a case, the data is being reported as o ne case in the final analysis.

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52 In qualitative research there are no computations or power analyses to determine the required minimum number and kinds of sampling units. Instead the relia nce is primarily on the quality of the information collected rather than the ac tual size of the sample (Sandelowski, 1995). Bogdan and Biklen (1998) and Patton (1990) indicated that qualitative research should be comprised of small numbers of information rich participants. This method allows the researcher to focus on the central i ssues of importance for the purpose of research. A sample size that is too large may become analysis of the data collected. The use of a collective case study provides the researcher a more direct approach to working with participants and obtaining more personal information regarding a specific situation (Bogdan & Biklen) Determining an adequate sample size is a matter of judgment and experience in evaluating the quali ty o f the information collected which will allow for the deep, case oriented analysis The result will be a new and richly textured understanding of the topic being studied (Sandelowski, 1995). For the purposes of this study the individual female participant s were each defined as a case H owever in the end the data collected is presented cumulatively. As a collective case study it becomes important to select a sample size that will provide the best amount of data for analysis without diluting the overal l analysis. The more cases studied the greater the possibility for lack of depth in any single case (Creswell, 1998). While balance and variety are important, opportunity to learn is most important when using a collective case study (Stake 1995). The g oal for this collective case study is to describe individual variations among the participants as well as identify common themes among the participants regarding maladaptive schema

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53 associated with their particular eating disorder. For these reasons this c ollective case study consists of interviews with ten adult females between the ages of 20 and 45 specifically diagnosed with anorexia nervosa (N=3), bulimia nervosa (N=3), or compulsive overeate rs resulting in obesity (N=4). Research Participants The goal of this collective case study was to describe individual variations and identify common themes among the participants regarding maladaptive schema associated with their particular disordered eating. This study included females between the ages of 20 and 45 who either fit the American Psyc hiatric Association (2000) DSM IV TR general diagnosis for anor exia nervosa or bulimia nervosa. The participants identified as compulsive overeaters were confirmed obese based on the Body Mass Index Scale which is calcul ated by dividing weight in pounds by height in inches squared and multiplied by a conversion factor of 703 (Center for Disease Control (CDC) retrieved 2009) which provided a reliable indicator of body fatness. This study excluded women who were considered obese due to an y type of medical condition. Participant Selection Bogdan and Biklen (1998) stated that qualitative research focuses on small numbers of information rich participants which allows the researcher to learn a great deal about issues of centra l importance regarding the purpose of the study. For the purposes of this study it was determined that nine participants, three in each category of disordered eating would provide rich and thick data which would allow this researcher to learn what was of central importance to this study, and what maladaptive schema are associated with each of the disordered eating categories which were the focus of this

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54 study. The participants were recruited through the University of South Florida Polytechnic (USFP) and the surrounding Polk County area located in the state of Florida. USFP is a regional campus for the University of South Florida and is located in Lakeland, Florida. It currently has a student population of approximately 3,450. This campus has a high per centage of female students at 64. 6% who hold an average age of 30.5 years and a mode age of 22 years (University of South Florida Polytechnic, 2009). Faculty were contacted at USFP and were asked for permission to attend one class session to spend no mor e than 10 minutes of class time to announce the study and identify the criteria for participation. A letter was provided to every student in the classroom (Appendix A) allowing them to review the criteria and make contact with the researcher outside of th e classroom to further discuss their participation. The letter clearly stated that the study involved the identification of maladaptive schema associated with disordered eating and the need to recruit participants diagnosed with anorexia nervosa, bulimia nervosa or who fit the criteria for obesity based on the Body Mass Index and who perceived themselves as compulsive overeaters. The letter also explained the exclusion criteria that if the person had a medical condition which caused obesity that person would not be eligible to participate in this study. Each student was provided with contact information to call the researcher so that an individual appointment could be made to further discuss the study and their commitment. Eight c lassroom visits were made by this researcher to recruit students and a total of six students volunteered and met the criteria to be come participants Because USFP is a small regional campus it was anticipated that not all the participa nts would be recruited from a single sour ce. For this reason the researcher also recruited through the Polk County community, particularly Lakeland and Winter Haven.

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55 These two cities host the largest populations in Polk County. According to the official website of Polk County Florida (2009) th e population of Lakeland in 2007 was 93,428 therapists in Polk County have offices located in one if not both of these two cities. A letter was sent to therapists and d octo rs introducing the study and this researcher and requested assistance in the referral of participants (Appendix B). The letter asked for an opportunity to meet with the clinician to further discuss the topic and gain support regarding referrals to the study. The letter also stated that no therapy was to be offered as a part of this study and that each of the participants would be referred back to their current therapist or doctor once the interview process was completed Four participants were referr ed to this study by local therapists for a total of ten participants, four compulsive overeaters resulting in obesity, three participants identified in the category of bulimia nervosa and three participants identified in the category of anorexia nervosa Any participant, who volunteered for the study that was not currently in treatment but wanted to seek treatment based on the interviewing process was referred to a therapist in the area currently treating disordered eating. Participant Characteristics App ropriate participants for this study were females between the ages of 20 and 45 years and diagnosed with anorexia nervosa, bulimia nervosa or who currently admit to compulsive overeating and who have been considered obese according to the Body Mass Index. Basic demographic information is displayed in Table 1. Each of the participants volunteered and showed an interest in the study.

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56 Table 1 Basic Demographic I nformation Code Name Age Ethnicity Disorder Cathy 35 Caucasian Obesity/Compulsive Overeater L aura 32 African American Obesity/Compulsive Overeater Margaret 35 African American Obesity/Compulsive Overeater Joan 25 Caucasian/Middle Eastern Obesity/Compulsive Overeater Carla 40 Caucasian Bulimia Nervosa Jane 28 Hispanic Bulimia Nervosa Donna 25 Caucasian Bulimia Nervosa Jillian 24 Caucasian Anorexia Nervosa Monica 29 Caucasian Anorexia Nervosa A ndrea 4 1 Caucasian Anorexia Nervosa Participant Descriptions Cathy: Cathy is a 35 year old Caucasian female who identified herself as a compulsive stress eater. Due to her compulsive over eating her weight has fluctuated between obesity and normal range according to the Body Mass Index. She was referred to the study by her therapist and volunteered to participate. She maintained a normal range weig ht for about 3 year s. However, she is currently in the process of her second divorce and her emotions have triggered her compulsive overeating As a result, her weight has increased to the range of overweight. She states she has tried numerous diet prog rams and can lose the weight, only to gain it all back. Because she has struggled with compulsive overeating and has weighed in the obese range for at least two years in

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57 the past, combined with her clear understanding that she uses food to cope with her e motions she was included in this study under the category of obesity due to compulsive overeating. Laura: Laura is a 32 year old married African American female who currently falls within the range of obesity for her height and weight. She admits to b eing a compulsive overeater. She is married and has two children. She is currently attempting to lose weight through what s he described as healthy eating. H owever, she admits that when she becomes stressed or anxious she can make all the wrong food choi ces as well as overeat. Her food journal does sup port this statement. She stated she has lost weight in the past using portion control and exercise but later gained it all back when she found that her schedule made it difficult to exercise at a gym. La ura volunteered to participate after the researcher spoke to her clas s about this research project. Margaret: Margaret is a 35 year old single African American female whose weight currently falls within the range for obesit y based on her height and the Body Mass Index She admits to being a compulsive overeater particularly when her mood is low, or when she is feeling overwhelmed or lonely. Her food journal supports this statement. She stated about five years ago she lost weight and was within normal range after her doctor warned her of the health hazards of being overweight. She indicated she is extremely disappointed in herself for not being able to maintain that normal range of weight. Her doctor has again warned her of the health hazards and she is motivated once again to change her eating habits. Margaret volunteered after hearing about the study from a friend on campus.

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58 Joan: Joan is a 25 year old single female who is of Caucasian and Middle Eastern decent. She volunteered for the study afte r this researcher visited her classroom at the university. She lives at home with her mother whom she appears to be extremely dependent upon. She stated that she struggles with her weight and her inability to stick to an eating plan that would keep her i n a healthy weight range. She admits to compulsively overeating when her mood is low and when she is feeling extremely anxious. Her food journal suggests that when she is under stress she does make poor choices about what to eat. Her current weight plac es her in the obese range on the Body Mass Index Scale. Carla : Carla i s a 40 year old Caucasian female who admits to binging and purging at the age of 16 and continued this behavior for five to six years. She did not seek treatment for bulimia. Once sh e joined the military she stated she stopped purging H owever she admits to continuing binging when she is anxious or distressed. She states she has not purged in 15 years. Currently she is overweight for her height but considers herself to be a healthy eater. Her food journal would suggest that she may not make the best nutritional choices and this may explain her weight gain. Carla is married and helped to raise her step daughter but has no children of her own. She volunteered for the study after he aring about it when this researcher made an announcement i n a class that she was taking. Jad e : Jade i s a 28 year old single Hispanic female who indicates she has struggled with bulimia nervosa since the age of 16. She stated that she has n ot purged in t he past two years. H owever admits to occasionally binging on food when she is anxious or distressed. She failed to return her food journal for confirmation of her current eating habits. She did not receive treatment speci fically for her bulimia nervosa; however she

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59 states she sought out a variety of 12 step programs looking for some type of support for her disease. She volunteered for the study after hearing about it through the counse ling center at the university. Donna : Donna is a 25 year old single Caucasian female who indicates she started binging and purging around the age of 16. She did not receive treatment specifically for her bulimia nervosa but has received treatment for other addiction issues. She states that currently she is working a 12 step program that supports her not only for her drug addiction but her disordered eating as well. She stated she has not binged or purged in the past two years. She failed to return her food journal. She heard about the study through her therapist a nd v olunteered to participate. Jillian : Jillian is a 24 year old Caucasian female who indicates she was diagnosed with anorexia nervosa at the age of 15. She has been hospitalized at least three times for this disorder due to her low weight. Her lowest wei ght at one time was 77 pounds. She continues to struggle with this disorder and is currently in outpatient therapy. She is attempting to maintain a weight above 100 pounds and at the ti me of this interview weighed 110 pounds. She is married with no chil dren. She heard about the study through the university counseling center and volunteered to participate. Her food journal suggests that she is still struggling with food choices and eating proper amounts to maintain her health and an appropriate weight. Monica : Monica is a 29 year old Caucasian female who indicates she was diagnosed with anorexia nervosa at the age of 15. She is marri ed with no children. She stated she was never hospitalized but did seek treatment on at least two occasions. She state d that her weight went below 100 pounds twice and her lowest weight was 90

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60 pounds. She is currently maintaining a healthy weight and has not had symptoms of the disorder for at least 7 years. She heard about the study from a friend on campus and voluntee red to participate. Her food journal suggests that she does eat a balanced diet. She indicates she learned to count points (calories) while in treatment and admits that she still tends to use this method to control her weight. Andrea : Andrea is a 41 y ear old Caucasian female who indicated that she struggled with anorexia between the ages of 17 and 21 years of age. She is married and has no children. She indicated that due to the emotional turmoil of graduating high school and then immediately moving with her parents to another state She was she lacked any control over her life. Her frustration, sadness and confusion about moving led her to not eat, and her weight dropped to dipping do wn to 80 pounds. She is in recovery but did share some maladaptive schema through the course of her interview for which she still struggles. Andrea heard about the study from a friend on campus a nd volunteered to participate. Data Collection Data collec tion consisted of interviews with four participants who self identified as compulsive overeaters and who m et the BMI criteria for obesity; three participants who fit the American Psychological Association (2000 ) DSM IV TR diagnosis of Bulimia Nervosa ; and three participants who fit the DSM IV TR diagnosis for Anorexia Nervosa. According to Patton (1990) interviewing is a technique used in research to understand the participant s perspective. Bogdan and Biklen (1998) indicate that interviews can be the ma in source of data collection in qualitative research. The purpose of the interview in this s tudy was to gather data using the pa

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61 this researcher could develop insight int maladaptive schema may be playing in the p articipants disordered eating. Questions In qualitative interviewing it is important to ask question s that are open ended in ordered to ensure that the participants respond in their own words (Patton, 1990). Open ended ques tions allow the participants to respond without feeling limited or restricted in their answers. This method increases the likelihood that their responses truly reflect their experiences related to this study. Open ended questions (Appendix C) were used r egarding a history of eating disorder, a description of family members, and home life which supported the flow of the conversation. The interview questions were based on questions that may be asked by any therapist conducting a standard psycho social evaluation to gather as much information as possible regarding family, home life, childhood experiences, trauma, conflict, and health, which might have contributed to disordered eating. These open ended questions were used successfully as p art of the pilot study and therefore were used as part of this expanded study. The general questions varied slightly based on the type of identified disordered eating. For example, those participa nts who were classified in the category of bulimia nervosa or anorexia nervosa were asked to provide as much detail as possible regarding the progression of the disorder (e.g., when it started, thoughts on what may have triggered the eating disorder; and the progression of the disorder). The compulsive overeater s were asked questions regarding the age at which each participant considered that they were obese, about childhood weight and the progression of the attempts to either diet or maintain a weight loss. Throughout the interviewing process the questions were intended

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62 to open the lines of communication. Once the participant began talking most of them answered the ques tions without prompting from this interviewer. Because the goal was to collect information through a conversational process this was an unstr uctured interviewing process The open ended questions were used as a prompt if the participant became stuck or got off track. Questions were included to obtain general demographic information including name, date of birth, ethnicity, eating disorder dia gnosis, weight details and a brief weight history. However, d ue to the size of the sample used in a collective case study attempting to use sampling variation based on race, class or socio economic background may not provide enough variation for meaningf ul analysis and could detract from the goals of the study (Sandelowski 1995) therefore limited demograp hic information was collected. Interview Procedure Licensed Mental Health C ounselor in the State of Florida. She has worked as a substance abuse counselor for approximately 20 years and has provided therapy and treatment services to people of all ages from adolescents through adulthood. Currently she is a counselor providing se rvices to students at the University of South Florida Polytechnic. As a college counselor she has provided therapy to several students with a variety of eating disorders struggling to stay in recovery. The interviews took place in the counseling office at the University of South Florida Polytechnic located in Lakeland, Florida. This office provided a comfortable, warm, and private atmosphere conducive to the interviewing process. The first meeting

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63 with each participant lasted approximately one hour. A t this session participants were provided with detailed information regarding the study. All questions proposed by the participants were asked and responded to by the interviewer. The consent form to participate in the study was reviewed and signed by th e participant. A copy of the consent is attached as Appendix D. Each participant was provided with a sample food journal (see Appendix E ) and was asked to track what they ate and what emotions they might have felt at the time for one week. They were ask ed to bring the journal to the next meeting so that it might be discussed as part of the interview. The second meeting lasted approximately one and one half to two hours in length and a more detailed recorded interview took place. As part of the pilot stu dy a list of words and phrases associated with maladaptive schema was created. These descriptive words were included in et al., (2003) definitions of each category of maladaptive schema (see Appendix F) The words Young et al., chose to describe maladaptive schema were listed without identifying the associated category. This list was only presented if a participant appeared to be stuck or at a loss for words to accurately describe a given situation. If the list was presented the participant was asked if any words on the list helped to describe thoughts or feelings they had about a given situation. The list was available but not always used if the participant was able to openly and freely express their thoughts and feelings. In order to record t he most accurate information, all interviews were audio taped with the knowledge and consent of the participant. Audio taping the sessions helped to cut back on but not completely eliminate note taking. Every effort was made by the interviewer to be obje ctive, empathetic, and accurate in the transcription of each audio

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64 taped interview. All audio tapes were kept in a secure location in order to protect confidentiality and will be destroyed once the study is completed. Once all the interviews were transcr ibed, each participant was invited to review the transcription in order to member check the data. This provided the participant the opportunity to review what was said and correct, exp and on, or delete information. Data Analysis The data collection culmi nated in an abundance of data to analyze. Qualitative analysis involves taking the accumulated data, and organizing it, breaking it into manageable parts, coding it, synthesizing it and looking for patterns (Bogdan & Biklen, 2003). For the purposes of t his study five strategies were used to evaluate the data: (a) analyzing the transcripts, (b) organizing the data, (c) coding, (d) memo writing, and (e) the use of a peer auditor. Transcript Analysis Patton (1990) suggested that the data can be described t hrough a case analysis which requires a complete case study for each participant, or cross case analysis involving grouping together responses from common questions across participants. The goal of this collective case study is to describe individual vari ations among participants as well as identify common themes among the participants regarding maladaptive schema which may be associated with their particular eating disorder. The two objectives for the analysis of the data collected were to first identif y maladaptive schema held by each participant and second to use a cross case analysis to identify common themes associate with specific eating disorders Th e first objective was accomplished through a case analysis of each transcript analyzing the inform ation presented by each participant

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65 indepe ndently of the others et al., (2003) defined maladaptive schema were identified and noted. Second, through the use of a cross case analysis, the transcripts w ere evaluated to locate common themes regarding maladaptive schemas associated with a specific eating disorder. The researcher sought to identify data which fit into each of the categories of maladaptive schema defined by Young et al. in order to support or refute the questions proposed by this study. In order to accomplish this task each of the 10 transcribed interviews were read and re read in an effort to become familiar with the information conveyed by each participant. Once each case was reviewed and the maladaptive schemas were identified, the findings were reviewed across cases to identify common themes among participants within the same eating disorder category. For example, all the participants with obesity due to compulsive overeating were co mpared to identify which maladaptive schema they held in common. Finally the data was analyzed in order to find themes or common threads that could link maladaptive schema to disordered eating, regardless of the specific diagnosis. All the cases were rev iewed to identify which maladaptive schema all the eating disorders held in common. Identifying what each eating disorder holds in common with the others may help to improve future treatment for eating disorders by allowing treatment centers to address co mmon maladaptive schemas in a general group setting Data Organization The researcher became familiar with the data by reading and re reading each reading each transcript was t o assure that the researc her had a clear understanding of each transcript in order to better identify and code the maladaptive schema that appeared. Lincoln and Guba (1981) suggest that to

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66 develop themes and categories involves deciding which data fits within a specific category and then flushing out information that will make each category more pronounced. As each of the transcripts was read and coded clearly unfolded. Each participant shared her experiences, beliefs, concerns and fears and as they did so et al., (2003) pre defined maladaptive schemas were identified. As each participant responded to questions and provided the details of her life and eating disorder her use of words and phrases were coded into each of the malada ptive schema that applied. For example, when Jillian was asked to describe herself black, very angry black. I hate re sponse was coded under the maladaptive schema of defectiveness and shame. It is clear by this statement that Jillian sees herself as defective and inferior which is one of the criteria for this category. More details regarding data coding are included in the next section. Data Coding Coding is the process of analysis in a collective case study. It is the way to take transcripts, field notes, and journals and dissect them in a meaningful way while keeping the relationship of the parts intact (Miles & Hu berman, 1 994). Codes are tags and labels used to assign meaning to descriptive information collected during the study. They are usually complex or straight forward chunks of information of varying sizes including words, phrases, and sentences connected t o a specific settin g (Miles & Huberman) that allow the researcher to reduce large amounts of data into manageable portions for analysis (Bogdan & Biklen, 1998). Once the interviews were transcribed and member

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67 checking was completed this researcher review ed and coded eac h transcript using et al., (2003 ) categories of maladaptive schema. Young established 18 categ ories of maladaptive schema which are defined as follows. Abandonment/instability is the belief that significant others do not provide e motional support, connection, strength or practical protection. Words associated with abandonment/instability include unreliable, unstable, unprotected, unpredictable, and abandoned. Mistrust/abuse usually is the expectation of being intentionally hurt. It involves the perception that harm is intentional or the result of unjustified and extreme negligence and may include the sense that one feels like they always end up cheated in comparison to others. Words and phrases associated with mistrust/abuse inc lude hurt, humiliated, abused, cheated, lied to, manipulated or taken advantage of. Emotional deprivation is the unfulfilled expectation of emotional support. This includes deprivation of nurturance, empathy and protection. Words and phrases associate d with emotional deprivation include absence of attention, lack of affection, lack of warmth, lack of companionship, lack of understanding, not listened to, unprotected, and lack of guidance. Defectiveness/shame is defined by Young et al., (2003) as the i ndividual seeing herself as defective, bad, unwanted, inferior or a belief that she is unlovable. Individuals may be hypersensitive to criticism which would make them very self conscious. They may also have a sense of shame regarding their perceived fla ws. Other words associated with defectiveness/shame include rejected, criticized, self conscious, blamed, insecure, and shame. Social isolation/alienation is described as feeling isolated from the world, being different from other people and/or not a par t of any group or community. Words or phrases associated with social isolation/alienation include lack of belonging, alone, being

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68 incompetence is the belief that one is una ble to competently handle daily responsibilities without asking for support or input from others. Words and phrases associated with dependence/incompetence include helplessness, unable to take care of self, lack of good judgme nt, not making good decisions According to Young et al., (2003) vulnerability to harm or illness is an exaggerated fear of preventable imminent danger that can strike at anytime. This could be caused by a medical, emotional or an external catalyst. Words and phrases associated with vulnerability to harm include danger, fear, something bad will happen, and destitute. Enmeshment/undeveloped self is a belief that a significant other cannot survive or be happy without constant support (Young et al. ). This may include feelings of being smothered by others or lack of individual identity. The ind ividual may be emotionally over involved with one or more significant others leading to a lack of separation or normal social development. Words and phrases associated with enmeshment and undeve loped self include no life of my own, lack of separate identity, need to give in to fundamentally inadequate in school, work, career, sports, etc. Words and phrases as sociated with failure include stupid, inept, untalented, ignorant, lower in status and less successful than their peers (Young et al. ). Entitlement/grandiosity is the belief that one is superior to others, entitled to special privileges or is not bound by rules that govern society. Words and phrases controlling behavior of oth ers, and lack of empathy (Young et al., 2003). Insufficient

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69 self control/self discipline is an extreme difficulty or a refusal to exercise self control and Words and phrases associated with insufficient self control/self discipline include the avoidance of pain, conflict, confrontation, and responsibility. Subjugation is a belief that one is coerced into giving up control in order to avoid making someone angry, being retaliated against, or abandoned by a significant other. There is usually a belief that their op inions, wants and desires are not important. Words and phrases associated with subjugation include suppressi on of desires and needs, feeling trapped (Young et al. ). Self sacrifice is an extreme need to put others before sel f. This is done in an effort to not cause pain to others as well as to not feel guilty or shameful toward self. Words and phrases associated with self sacrifice include care for others, good listener, doing too much for others and not enough for self (Yo ung et al., 2003). Approval seeking/recognition seeking is an extreme emphasis on gaining approval or fitting in at the expense of developing a true sense of self. Words and phrases associated with approval seeking/recognition seeking include gaining app roval, recognition, and self esteem is dependent upon others. Negativity/pessimism is a life long focus on the negative and minimizing the positive aspects of life. Words and phrases associated with negativity/pessimism include fear of making a mistake, wo rried, indecisive, and lack of spontaneity (Young et al. ). Emotional inhibition is defined by Young et al., (2003) as the inability to spontaneously react, feel or communicate in an effort to avoid disapproval by others or feelings of shame or losing cont

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70 emotional inhibition include insecurity to show joy, affection, sexual excitement, and vulnerability. It includes insecurity to express feelings or needs. Unrelenting standards/hyper criticalnes s is the belief that one must strive for very high internal standards of behavior and performance to avoid criticism. Words and phrases associated with unrelenting standards/hyper criticalness include perfectionism, inordinate attention to detail, rigid r ules, high moral and ethical percepts and preoccupation with time. Punitiveness is the belief that people should be harshly punished for making mistakes and that they should not be forgiven for their mistakes. Individuals have difficulty forgiving mistak es in themselves and in others. Words and phrases associated with punitiveness include angry, intolerant, impatience with others and lack of forgiveness (Young et al. ). As each case is being reviewed independently of the others, a matrix was set up which included the et al., named maladaptive schema, the ed to fit within the definition of each of those maladaptive schema. The matric es are pre sented in Appendices G through P For cross analy sis of the data a second matrix was developed by category of disordered eating in order to identify themes within each category of disorder eating and across all the categories et al. (2003 ) maladaptive schema. The results are presented Table 2 and disc ussed more fully in Chapter 5. In table two disordered eating is identified as Compulsive overeaters resulting as

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71 Table 2 Relationship of maladaptive schema to each of the disordered eating categories Disorder/ Maladaptive Schema OE OE OE OE BN BN BN AN AN AN Abandonmen t X X X X X X X Defectiveness X X X X X X X X X X Dependence X X X X X Emotional Deprivation X X X X X X X X X Enmeshment X X X X X X X Entitlement X Insufficient/ Self Control X X X X X X Mistrust/ Abuse X X X X X X X X X Subjugation X X X Social Isolation X X X X X X Self Sacrifice X X X X X Emotional Inhibition X X X X X X X X X Failure X X X X X X X Unrelenting Standards X X X X X X X X X Vulnerability to Harm X X X X X X Approval Seekin g X X X X X X X X X Negativity Punitiveness X X Memo Writing Memo writing i s the process of writing notes throughout the data analysis process Memo writing may support analytical thinking, insights and learning on the part of the researcher (Bogdan & Biklen, 1998). For example, w hile reading each transcript, this researcher ma de notes as specific statements appeared within the transcript that could

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72 possibly be associated to maladaptive schema. This led to better organization of themes that occurred throughout each transcript and across transcripts. Writing notes in the margin s of the transcript allowed this researcher to identify themes and capture thoughts as they occurred. Audit Process Another strategy in the final analysis of a qualitative study is the use of an auditor to increase the dependability, confirmability, and c redibility of the process. Because prior experience could lead to drawing conclusions too quickly this rese archer used an auditor nd the use of an auditor may help with this process. Lincoln and Guba (1985) describe a five stage process. The first stage for the researcher is to select the auditor and describe the study, how the data was collected, and the procedure for data analysi s. An auditor was selected who is a counseling colleague with some previous experience in disordered eating and was willing to apply a critical eye in the coding of maladaptive schema. Background information on the aud itor is attached as Appendix Q The to accomplish this the selected auditor was provided with a copy of the dissertation et al. (2003) categories and definitions of ma ladaptive schema. The auditor familiarized herself with the data collected. Clean copies of each of the transcripts were provided and a formal agreement was reached regarding what should be accomplished by the audit. The auditor was also asked to provid e a written report of her findings which is attached as Appendix R The auditor

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73 agreed to provide the service at no charge with an agreement that the favor would be re turned at some later time. Stage three is the determination of trustworthiness and req uires the assessment of confirmability, dependability and credibility. This was accomplished by the researcher and auditor reviewing the transcripts and making a comparison of each of their findings. In reviewing the data the auditor followed the same pr ocedures as the researcher. The auditor reviewed and confirmed the audit trail and det ermined that the results were due to the data provided and not a result of researcher bias. Credibility was established by determining that the transcripts were an accu rate depiction of the interviews. The fourth and final state of the process is closure In this stage the auditor and researcher discussed, processed, and noted any feedback and the auditor submitted her final report (see Appendix R ). Establishing Trustw orthiness It is important not to try to fit qualitative research into a quantitative design model H owever that does not mean that qualitative research should ignore the tenets of validity (Tyler, 2002) or recognizing that there may be threats to the re search. An effort was made to not allow these threats to influence the outcomes. Lincoln and Guba (1985) found that the terms of validity and reliability that fit well in quanti tative analysis do not work in qualitative studies and recommend that qualita tive researchers consider credibility, transferability, dependability and confirmability A ll of which were considered throughout the course of this research. Lincoln and Guba suggest several activities which can help to establish credibility to the rese arch including prolonged engagement, member checking and triangulation.

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74 It is also important to consider research bias as a part of credibility. Prolonged engagement is the investment of sufficient time to build trust (Lincoln and Guba, 1985). For the purposes of this study prolonged engagement included meeting with the participants prior to the interview process to explain in detail the purpose of the study, review the consent form and answer any questions and concerns the participants might have regar ding the study. An effort was made to make the participant comfortable prior to the interview process in order to gain their trust and willingness to participate at a high level during the interview process. During the interview process each participant was allowed to talk at their own pace and provide information in whatever order they were comfortable. Establishing a trust ing relationship in advance helped to create willingness on the part of the participant and allowed the researcher to capture detail ed personal and sometimes emotional inform ation in support of the study. The research er counts on member checking to assure that the intended meaning of the transcribed information is accurate and the participants can provide a critical review of the coll interpretations (Stake, 1995). On occasion a participant may find something with in the transcript that is considered objectionable and therefore it is important to make the effort t o work with the participant to clear up any type of misunderstand ing or information that they believe may have been misstated. The participant may provide alternative language or re interpret information provided earlier (Stake). For the purposes of this study the participants were asked to examine the transcription of their audio taped interview for accuracy and palatability. This session was also recorded in case the participant wanted to add, delete or change information presented earlier. Only one participant added further

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75 information to her transcribed interview. That information was then added by the researcher and she reviewed the transcription a second t ime without making changes. Seven of the participants reviewed the materials without making changes, deletions or additions and two participants opted not to read the transcription and approved its use as is. This may be considered a limitation of the study and will be discussed more fully in a later chapter. Triangulation occurs through the use of different modes such as interviews, questionnaires, observation or testing (Lincoln and Guba, 1985). For this study and asking the participants to keep a food jour nal prior to the interview process. During the course of the interview the researcher found that information being presented triggered new questions or a more detailed discussion. As these moments occurred she made notes to ask further questions or clari fy information. The food journal helped to provide an understanding of eating behaviors (see Appendix E ). Each participant was asked to chart when and what they ate and for what reason (e.g., hunger, emotional issues, anger, fear). The food journals wer e returned at the second meeting and were discussed as part of the recorded interviews. H owever, two participants failed to return the journals. This may be a limitation of the study which will be dis cussed in a later chapter. Research er bias can be see n as a threat to credibility in a qualitative study. Researchers may have a tendency to overweight facts they believe in and to ignore data not going in the direction of their reasoning and to see confirming data far easier than nonconfirming data (Nisbet t & Ross, 1980 as cited in Miles & Huberman, 1994). Researcher bias may occur when data is selected by the researcher that seems to

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76 2002). In order to avoid bias, this researcher prepared a list of carefully though t out questions to be asked as part of the interview process and used self awareness during the interview process to allow the participant to lead the conversation. The researcher asked clarifying question wh en it was deemed appropriate H owever the prepared questions were followed in each interview. Also, the use of an auditor helped to ensure that the data collected was analyzed properly avoiding researcher bias. Transferability is the degree to which sim ilarities exist between contexts that allow findings to be transferred from o ne situation to another (Murphy et al., 1998 as cited in Plack, 2005). Creswell (1994) suggested that the use of thick descriptions can provide a solid framework in which to make comparisons which allows transferability to occur. It is the responsibility of the researcher to provide detailed descriptions so that the reader can judge the transferability of the data (Robson, 1993, as cited in Plack). This removes the onus of trans ferability from the researcher to whoever may attempt to generalize the information from one context to another (Plack). The goal of the researcher was to provide thick rich data and explanations which would allow for transferability of t he findings to ot her contexts. Dependability comes into play during the analysis of the data. Dependability in a qualitative study replaces the quantitative concept of reliability (Tyler 2002). In order to raise the dependability of this study three techniques were use d. First, audio tapes were made of ea ch interview with a participant, and each audio tape was transcribed verbatim. Second the tapes were listened to all the way through for a second time to check for accuracy to ensure that the words spoken were in fa ct the participants and not those of

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77 the researcher. Third an auditor was used to examine both the process of inquiry as describe d earlier in this chapter. Using an auditor helped to determine the acceptability of the process and confirmed t he dependab ility of the study. Confirmability is the qualitative equivalent to objectivity in a quantitative approach (Tyler, 2002) and the audit is the technique used to establish confirmability. The auditor reviewed each transcript independently from the researc her. The auditor examined the audit trail by reviewing the transcripts, the data reduction matrix and the themes, categories and relationships produced and established the confirmability of the study in a written report (Appendix Q ). Summary Chapter 3 pr ovided a detailed explanation of the methodology that was used in this study including descriptions of the participants, the research procedure that was followed and how the data was analyzed. Chapter 4 will provide the results of the study.

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78 Chapter 4 Results Chapter Three presented the methodological procedures followed during this collective case study. The study concluded with 10 participants, four in the category of obesity due to compulsive overeating, three participants who met the DSM IV TR ( American Psychiatric Association 2000) diagnosis for Bulimia Nervosa and three participa nts who met the DSM IV TR (American Psychiatric Association 2000 ) diagnosis for Anorexia Nervosa. Each of the participants was interviewed and the transcripts were analyzed in order to further explore maladaptive schema associated with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity to better understand recovery and relapse in disordered eating. The research issues explored were: fi rst, to identify the maladaptive schemas which may be associated with anorexia nervosa, bulimia nervosa and compulsive overeating result ing in obesity in adult females; and second to identify which of these maladaptive schemas are held in common by these disorders. Exploration into the identification and effect of maladaptive schema associated with disordered eating may further develop and improve treatment increasing the opportunity for recovery and decreasing the rate of relapse. The data analysis w as described in Chapter Three along with a discussion of the concepts of credibility, transferability, dependability, and confirmabilty of the data and research design.

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79 Chapter Four begins by presenting the results of each case study. These case studies are presente d independent ly of each other. The cases are grouped according to eating disorder and presented with other cases within the same type of disorder. Each partici own words. Background information and the details a ssociated with each identified maladaptive schema, are also presented to provide a better understanding of the participant s li fe events which have led to a specific maladaptive thought Quotes from the participants are used to show the association to a s pecific maladaptive schema. These quotes are presented in the first person in order to identify that these are the words used by the participant. This is considered a common practice in qualitative research P resenting the quotes in the first person all ows the reader to be less distanced from the participant (Seidman, 1991). As each participant tells her story, discussing her thoughts and feelings regarding family and her specific eating disorder maladaptive schema are identified and noted. The common themes from each disorder that developed during data analysis are introduced. The data is sorted by eating disorder and the common themes that appear within each eating disorder. Then the data is cross analyzed to find themes that are common to all three d isordered eating categories. et al., (2003) 18 defined maladaptive schema. Each participant made comments that fit into one or more of these maladaptive schema. The 18 categories are: (1) abandonment/instability, (2) d efectiveness/shame, (3) dependence/ incompetence, (4) emotional deprivation, (5) enmeshment/undeveloped self (6) entitlement/grandiosity, (7) insufficient self control/self discipline, (8) mistrust/abuse, (9) subjugation, (10) social isolation/alienation, (11) self sacrifice, (12) emotional inhibition, (13) failure, (14) vulnerability to harm or illness, (15) approval

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80 see king/recognition seeking, (16) u nrelenting standards/hyper criticalness, (17) negativity/pes simism, and (18) punitiveness. Case Studies her story in her own words. Each category of maladaptive schema that applied as the story unfolded is identified and discussed within the case study presentation. The o rder of presentation is four case studies representing compulsive overeating resulting in obesity; three case studies representing bulimia nervosa ; and three case studies representing anorexia nervosa. Obesity Associated with Compulsive Overeating Four wo men volunteered to participate in this category. Three of the four currently meet the Body Mass Index definition of obesity based on weight and height. The fourth participant currently meets the Body Mass Index definition for overweight based on weight a nd height but admitted that while she currently is overweight her weight in the past has been in the obese category. Because she successfully lost weight and was able to reach a normal weight range but has been unable to stay within that range she was acc epted as a participant. It was believed by the researcher that this participant would reveal maladaptive schema which could explain her inability to keep her weight within a normal range. All four women admit t ed to being compulsive overeaters. They all indicated that they use food as a source of comfort during times of stress, anxiety, and sadness. As each participant tells her story it can clearly be seen th at each has unresolved trauma which has resulted in maladaptive schema.

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81 Cathy Cathy is a 33 year old Caucasian female who volunteered for this study after hearing about it from her former therapist She is a single mother of three children. Her weight at the time of the interview was 170 pounds. For her height of 5 feet, 5 inches this is considere d overweight based on the Body Mass Index (BMI). She stated that her heaviest weight has been 222 pounds. This weight falls within the BMI range for obese. Over the course of the past two years she reported her lowest weight was 145 pounds, which is cons idered within normal range. She indicated that she recently finalized a second divorce and during that time her emotional eating was out of control. She attributes her weight gain to her emotional turmoil during the separation and divorce. She indicated she has returned to her Weight Watchers food plan, and has begun exercising again in an effort to get her weight back to 145 pounds. She failed to return her food journal. For the purposes of this study Cathy was p laced in the category of obese due to h er admitted compulsive emotional overeating, her inability to maintain her weight loss and that for at least two years her weight was in the obese range Cathy repo rted that she was molested by her father until the age of 13. She stated confused about having to lose her husband in order to protect her children. Cathy stated that things were quite confusing and frightening for her during that time. Her mother had a hard time staying away from her father and at one time Cathy feared they would have to move back in with him. The father was also a drug addict and the mother was constantly trying to rescue him. The mother eventually did give up her efforts to reconcile the fami

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82 played out through her own discussions in this interview regarding her personal need to th the babies because that is Throughout the course of her interview Cathy made statements that fit into 12 et al., (2003) 18 maladaptive schema s As an adult Cathy continues to believe that she should have a relati onship with her father and that he chooses not to be a p art of her life, Her perception is that he has abandoned her even though she believes she has forgiven him for his behavior when she was a child. Another area of abandonment revolves around her first marriage. Cathy became pregnant at the age of 16 and married the father of her child. However, this marriage did not last long. She indicated that he was not home much of the time and she was alone to care for a small By the age of 19 she was divorced and caring fo r her son on her own. Cathy also made several statements related to defectiveness and shame The first is a description of her father who she perceived as defective. In describing him she stated : It is almost to the point where he had demons. I felt lik e as a child and even grown up today that he has demons. Or a devil has just taken over his body because he is not a good person when he is on drugs and drinking. When she was offered the list of words and phrases and asked if any of the words help ed her to better described her father she stated :

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83 Cathy made several comments suggesting her thoughts regarding her own defectiveness and shame As she st father use to verbally abuse her mother often and Cathy believes she internalized his comments and applied them to h and he would put her down. So I think seeing that I then internally was putting that in my problems and tha t many times this happens when she is driving her car. Her concern was I am driving down the road with no Bluetooth in my ear or anything just talking and hoping no her as defective. She also mentioned talking with her therapist regarding her defective would feel bad about Cathy talked a lot about her second divorce and her defective thoughts regarding her success as a wife and mother. are all a a l ot and put myself down inside. She has struggled to see herself as others do, showing her thoughts of defectiveness. She indicated that she had been discussing her weight issues wi th her mother who attempted

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84 would say an outsider looking in they would say Cath y is very successful. Cathy says this is luck. And why are the Cathy talked about her compulsive over eating She admit t ed that when she is feeling emotional she tends to gravitate toward food to find a source of relief or co mfort. Her most recent experience revolved around her separation and divorce from her second husband. She went through periods of questioning her ability to be a good wife and mother and during that time she would find herself compulsively eating in an effort to make herself feel better. Later she would regret her use of food to find relief. She recalled her own feelings of defectiveness and shame relating to this divorce when she stated: I was sitting there crying and I am just shoveling piles in my m outh and all of the sudden I looked down and realized oh my gosh almost the whole bag was gone, and I opened the bag. And I said Cathy what is wrong with you? What is seriously wrong with you? Cathy indicated that at one point she gained weight and f elt that part of the reason was because there was no one telling her not to. This is a sign of her dependence upon others to provide her with direction and guidance. She indicated that during her second marriage she found that her husband woul d love her no matter what : at that point I thought telling me, I wish this or I wish that like about her recent divorce and her dependence on he r e x husband to help her make the decision to follow through with the divorce. She filed the paperwork at least two years earlier and then moved the hearing date several times because she was not clear about what she really wanted. She indicated:

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85 This is the second time I have been married and I am failing. What is wrong with me? And so finally my husband said you need to do something and we finally came to the decision to mo ve forward and we got it done. This statement not only shows her need for someo ne else to help her make decisions it again points out her defective thoughts about herself. She also comments about her need for support in other areas. When she is attempting to watch what she eats she is depende nt upon friends to tell her what she sho uld not be eating and expecting friends to push her to work out on a regular basis. She is motivated but struggles to do any of this without support from oth ers. She indicated: It is always good to have someone to do it with. Right now my friend is join ing me in the gym and we are putting together our plans of what we are going to eat and really paying attention to that. So I think her and I together can make it work because she lost a lot of weight too when we did it together. I would surround myself with people and say look if I do this you got to say something to me. My this understanding. She never had to hit me. I got it. Cathy expressed a sense of emot ional depriva tion when she talked about her mother. After Cathy told her mother that she was being molested by her father, her mother went through her own person al confusion. During that time Cathy believed her mother focused more on trying to fix her father and the family tha n she did trying to support her her attention on her children and emotionally deprives her grandchildren She perceives her mother as feeling guilty for w hat she put her children through when they were young and therefore she over focuses on trying t o make up for that now. Cathy believes her mother should be focusing all her love and affection on her grandchildren and ignoring her children She stated:

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86 She loves her children, puts them first over anybody. It is so much to a point trying to make it up to us not realizing that what we really want is the love for our children. That would make me happy. She also commented that her relationship with her brother seems to lack the emotional very factual and does not want to hear that fluff s tuff. He likes to pick on me, he likes to push my buttons and get me all riled Cathy expressed some feelings of enmeshment regarding her relationship with her daughter and youngest son. She believes that she was too young to appreciate her oldest so n when he was a baby because she was still growing up herself. She now admits that she is doing those things with her p Cathy expressed statem ents indicating some maladaptive thoughts in the area of insufficient self control. Related to her use of food for comfort she stated: I like comfort food. It is what makes me fe el good. It works for a minute. T hen you are uncomfortable as you r e goin g oh I feel horrible. was so desperate to do something without realizing that the real issue was within me. I cried every day, I ate, I ate late, super late because I would go to bed late. Sometimes two or three in the morning s o I would be eating and that is not a good time to eat certainly, but that was the comfort. It is a glass of milk and some cookies or pie sitting there watching television. mole sting her as a child. Later her first husband had several extra marital relationships and in getting his own way t wisting it toward where it worked out to his be about her second husband and how she had so much confidence in his ability to love and

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87 trust her own father. She indicated that at times it is tough for her to watch her daughter and second husband together because it is the relationship she has alwa ys wanted with her own father. Cathy considers herself a m aster at suppressing her own preferences, decisions, and desires The tone in her voice indicates she takes great pride in this ability. It would not be surprising to learn that very few p eople know her as well as they may think they do She is very c hameleon like in her behavior. I have seen people all my life who say that is a mean person. I have never wanted to be that person that someone speaks at the dinner table about. Have I not l ike d people? Absolutely but they would never know it dealing with them because I just have always believed that. Personality wise I can walk up to a group of people and just chit chat about whatever and pick up very quickly what interests them and then h ave a conversation around that and I m ay not know anything about it evaluating her words it appeared that this is her way of suppressing her own values, thoughts and opinions in order to fit in. Cathy made several comments that fit into the category of emotional inhibition. She stated: T I ime to eat certainly but that was the comfort. I would comfort myself going through that the pain of the outside and the hurt of the heart and say all right if my stomach is hurting like crazy t hen it takes everything else away.

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88 Cathy was asked if there was any specific event that caused her to eat more than She was also asked what she thought she gained by eating and she feeling good at that Cathy struggles with a sense of failure even though she has had several successes in her life. She has been very successful at work, having moved up into a management level at a very quick rate. She struggles to understand what it is her bosses see in her and considers that for the most part her advancement has been pure luck. She has impressed her employer so much that she has been place d in a management role that normally ree. Cathy has completed a two year college degree but on the part of her company and that eventually someone will figure out that they have made a mistake believing feeling like she is a failure when it comes to marriage by stating: When I got divorced my thoughts were I am just not good enough. What it says about me is that I failed. This is the sec ond time I am married and I am f ailing at it. I put it all on myself. Maybe this is your fault. Everything points to you. Cathy puts herself down suggest ing that not only was she unable to be successful in a marriage but that she must also be a bad mother because her kids are required to spend time with each par ent separately. She lamented: I felt like I am not a good mom because my kids are all apart an wife because you know this and that. You pick apart all the things you do in the whole marriage and you think I could have done this better.

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89 While she is seeing herself as a failure at the sam e time she may be hypercritical expecting t hat she should have done better. She talked often during the interview about wanting to be ng able to make this second marriage work. She states of her ex for any person better. Sometimes it makes me angry at him, because I wanted that, I Cathy made several comments that fit in the category of approval seeking. She continuously worried about what people may think of her. Cathy alway s presents herself with a smile and full of energy. It would probably surprise many people to find out that she does not consider them friends e ven though she appears to be friends with everyone. She girl was the coolest person in the world, or the neatest person, most interesting or She a lso commented several times about how important it was to her to be seen as successful by other people yet doubts her own success showing a need to have others validate her. I want people to see me as successful. So I really, really care what people think about me. Almost too much. ...Even today I care about what people think about the group settings and bragging and saying yeah I did it too and look what we can do together. Cathy is also concerned with how her children see her. She indicated that her sadness, crying and much of the compulsive eating happen when her children are not at home or are asleep:

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90 2 et al., (2003) maladaptive schema. The majority o f her comments fell within four distinct areas; defectiveness/shame, dependence/incompetence, emotional inhibition, approval seeking, and failure. Cathy continues to see herself as defective and a failure. She attempts to mask those feelings with food. This becomes a vicious c ycle for her because she is aware that she is eating in an attempt to make herself feel better yet admits that in the end it only makes her feel worse. She failed to return her food journal. This may be a sign that she continues to struggle with her emotional eating. Writing down her food choices and emotions that go along with eating may have been too visual and more than she was willing to see at the time of this interview. Her continued struggle with losing and regaining weight indicates that she will continue to compulsively eat and that some of her maladaptive schema do interfere with her weight loss success Joan Joan is a 25 year old single female of Middle Eastern and Caucasian decent. She is 5 feet and 4 inches tall and currently weigh s 216 pounds which places her in th e obese range based on the Body Mass I ndex. When asked how much she weighed she stated she thought between 200 a nd 220 but that s he found it depressing to weigh herself. The scale indicated she weighed 216 pounds. S he asked not to be told what her actual weight was. Joan volunteered for the study after hearing a presentation regarding the research in a class she was taking at the university. Through the course of the interview J oan made statements which fit 11 et al., (2003) maladaptive schema categories. Joan was raised by a single mother. She stated that when her mother became pregnant that she ba

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91 apparently worked as a bartender in the town where her mother lived. The y dated and she became pregnant. She decided to keep the baby but not to marry the father. Joan has never met her biological father. S he recalled that her mother dated often while Joan was young, suggesting that it was her mission to find a father for Joan. Joan expressed What realize was that she was pushing me away by not spending time with me. I felt getting any attention. Joan stated that her mother never encouraged her to seek out her bio logical father Joa n believed that her mother feared steal her when she was young. Her mother feared that he would return to his cou ntry with Joan Because of her fear he t own where he lived after Joan was born and did not make any attempt to stay in contact or let him know where arted counseling . This also plays into feelings of being abandoned and unwanted by her father. 1 different categories one area of major concern were the statements she made about herself and her appearance which fell in the category of defectiveness and shame. Her first simple comment regarding how weighing herself makes her feel depressed is one example of her thought s regarding being ashamed of her appearance and as long as she does not know how high her weight is she can deny the

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92 She also commented on several occasions regarding how she perceived herself as looking different than other girls as a child due to her ethnicity. She stated: I how much of a self esteem issue I have becau se of my ethnicity. when I was in kindergarten or first grade that I started having doubts about my self esteem and about the way I looked because all the girls in my school were s nd so I always felt different from the other girls. And I remember even girls making fun of me when I was younger and calling me fat and saying things like that. My back was curved and my stomach poked confide nce in myself because of that. Joan also commented about how her happines s was tied to the idea that she was not thin when she stated : My whole life I thought that if I am skinny I will be so happy. And then it was could get rid of all those things at the same time then things would be great. At some point Joan was able to loose some weight and the braces on her tee th were removed, but she still worried about how defective she might be. She indicated: I remember being more paranoid about my self esteem because I thought well I got to be s omething I am doing wrong with me instead because if you are overweight is fine. I pretty on the outside e steem a lot wrong with you. And you are n ot as pretty as everybody else. Joan mentioned a n embarrassing situation that has caused her some concern over the years. She was at a family picnic where watermelon was being served. She wanted to be able to take some of the watermelon home to eat later in the evening. She asked her mother if that would be okay and her step grandmother responded in front of the entire

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93 Later in the day when Joan discussed her embarrassme nt with a cousin, the cousin it. It is your fault as she struggles with her feeling s regarding her ability to succeed in school. Although she is an A student and has been succe ssful each semester she commented : When I get half way through the semester I get so depressed and hopeless and I That Joan made comments specifically about her relationship wit h her mother when she was young that appear to fall in the category of emotional deprivation. Along with apparently tired and did not spend the time with Joan that s he would have liked: I did have a lot of babysitters when I was little. And my mom was, she worked full time. She would come home and on Sunday she would sleep all day. And I remember watching TV because that would keep me busy. I remember waking up my mom a lot. Hey mom can I eat the Doritos? And she would say no you can have a bowl of cereal. And I would be like please, please, can I eat the Doritos? And I remember eating a lot. I would have a little carpet picnic and eat lots of food. And I don like three or four bowls of cereal over five hours. Joan expressed some confusion regarding her father due to some mixed messages f rom her mother. Her mother use of her commented that if her father really wanted to find them he always has known where they are. Because of this Joan expressed a concern that fit in emotional deprivati on

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94 my dad around. strongest area of maladaptive schema is her enmeshment with her mother. Her mother has alienated herself from other family members including iological father. Joan commented early in the interview : has always needed my help. Probably if she has told me once she has told me a million times tha t I am the want anything to ever happen to me and that nobody is going to ever hurt me no matter what. Joan also commented on her sense of res ponsibility toward her mother. When I was younge cheer the person up and say oh mom you are not fat or you are pretty or I love you. Or you start to take it out on yourself and say well if my mom thinks that then maybe that is what I should do. Y ou start to think it is normal and you start to do it to yourself. And I realize I do that to myself. The conce rn for her safety Joan explains is more her if her biological father found her he mig ht try to take her away to the Middle E ast where she would never be seen again. Joan also believes everything her mother has told her about her father without qu estion. She stated : Whenever I asked her a question she would always tell me the truth no matter h ow difficult it was for her. Or she would tell me I will tell you in a few years. could talk to my mom about anything. truggled with weight issues As young as 13, when her mot her would diet Joan would join her in eating the same foods, or going to the gym to

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95 reg arding food and enmesh ment came when Joan stated: food. asked to clarify who she meant when she used the word we point wher referring to her relationship with her mother. Joan at one time recently thought she might like to find her father. When she discussed the idea with her mother she stated: I remember u s talking about it for about three hours straight crying. And it was exhausting trying to have a conversation and trying to understand her point of view because in her mind she had tried to protect me during this whole, during my whole life and it was lik e I was throwing that in her face if I wanted to meet him anyway. Joan opted not to find her father after their conversation. H owever many of her reasons fall within the next category of maladaptive schema, mistrust/abuse. She stated: I was almost conv him once just to see what he was like. But I was kind of scared because what if he is not what I expect. What if he is not a nice person? And then all of those fears that I have been associating w ith someone that is not a good person would come true. And then I would start to internalize that and say well if he is like t hat and he is half of me what does that make me? I was unsure about that. And I was She also associated her lack of trust in men to her lack of a relationship with her father when she stated : the only guys I saw that were around my mom I thought the only rea son they were around her was because they wanted something. I thought they just wanted her

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96 le with it. Trying to understand how there are good guys out there but so many of them are bad. It is just a complicated situation. mistrust Joan commented: My mom always tried to be really careful with me and would say you need to always be aware of your surroundings and those type s you have to be aware of your surroundings and you need to be careful. And I remember her also saying something about if someone is looking at you look them in the eye because that means they know y ou are not someone who is shy. People were appea has translated that into mistrust of men in general people start noticing me especially guys in Wal Mart I thought it was for dirty reasons. I s with subjugation also coincide with her relationship with he r mother. Her mother has been the authority figure in her life. She has made all the rules, and b een very over p rotective of Joan due to her personal fears. As this has played out for Joan she has simply complied with her mother s wishes, even admitting that as an adult she struggles to stand up to her mother. Joan justifies her mother s action as follows: And I think in her mind she was trying to protect me because the town she grew same p rejudices that she may have faced or others may have faced. And so she and it was so confusing for me because I was like, well how is it that I am not suppose to be ashamed of who I am but I am not suppose to tell anybody where

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97 want him to find us and take you away. This behavi or also helped Joan feel very socially isolated however other things played All the other girls were skinny and they could shop in the skinny girls sections. I Joan also made comments regarding emotional inhibition. She attempts to con trol her emotions with food enmeshment with her mother. She also c She went on to explain: When I was little I think it was more boredom t han anything. Now I think it is emotions I mean when I get upset. bad day and I find out there I am really upset and eat certai n foods I usually feel better. have a bad day at work or I am really stressed out or I am in a really bad mood I will eat. Or a lot of times when I am home and see something good on TV or I and you feel so much better. Joan made one comment regarding her issue with failure to achieve and it centered around her in ability to be successful on a diet or food plan. She tried entering her calorie intake into a program she found on a computer website. H owever she commented: I would think that I was doing really good and it would say I went over my limit all the time. And I wa in the data base either so it wa much progress so I stopped using it.

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98 Joan also comments on her unrelenting standards for herself. During her adolescence when she was trying very hard to fit in with her peers she s tarted doing pu shups and stated: pushups and sit ups for 30 minutes ever y night. I would test myself all the time to make sure my abs were tight. I remember be ing preoccupied Finally there of approval seeking. This area of ma ladaptive schema also appears to be significant in her life. The biggest area of concern for her appears to go back to her issues with her ethnicity. to find one to identify wit h. I wish I could marry an Italian or American Indian or some other culture that I look like that I can envelop myself in and be absorbed by part of a culture that nobody likes She also comments about her need to fit in when she and her mother joined a gym to go work out. She stated: I think I loved it because you are in the club now. Because everyone is working out and talking about their gym and I could say I go to the gy m. And it was just fun to be one of those people. She commented further regarding her need to fit in: what size you are and having confidence. And it is really hard to have confi dence perceive you and those types of things. I was always the bigger person in the group. accepted a nd you want to be able to buy the clothes that everyone else is wearing and that was hard. She continues to find it a struggle to understand where she fits in whether it is at school, work, or at church.

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99 While Joan made comments throughou t her interview that fit into 11 et al., (2003) maladaptive schema, f our areas appear ed to stand out as the strongest areas of concern These may pl ay a role in her inability to l ose and /or maintain a stable, healthy weight. Her thoughts about her appearance elicite d strong statements regarding her defectiveness yet she is not ready to know how much she really wei gh s. Not wanting to know what she weigh s suggests that she is not ready to do the work necessary to lose the weight using a nutritional food plan an d working on issues that trigger her compulsive eating. The second largest area of concern is her enmeshment with her mother. Her This does not allow her to expre ss herself as an individual. Other categories where Joan made strong statements were in the area of mistrust/abuse, approval seeking and emotional inhibition. These areas of maladaptive schema stem from early childhood memories and continu e to cause prob lems for her based on her inability to lose and maintain a healthy weight. Laura Laura is a 32 year old Black female. She is married with two children. Laura current weight is 274 pounds. Her height is 5 feet 6 inches tall. For her height she does fa ll in the obese range according to the Body Mass Index. She stated she recently lost about 20 pounds and believes that her highest weight was three months ago at 295 pounds. Her current weight loss plan includes trying to make better food choices H owev er her food journal suggests that she is struggling to stay on that plan. She admits that she eats when she is bored, emotional, feeling down, frustrated and anxious. At one time she was able to get her weight down to 140 pounds through consistent exer cise. She

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100 stated that she thought that was the best weight for her height. She stopped exercising and stopped smoking and her weight has gone up continuously over the course of the last 3 years. Laura volunteered for this study after she heard a present ation regarding the research in a class she was taking at the university. During the interview process Laura made statements that fit into 11 et al., (2003) 18 maladaptive schema. ng defectiveness and shame stem from the relationship with the gentleman she refers to as her father, as well as, several comment s she made regarding a n abusive ex boyfriend rejected, blamed and insecure by both my father and my former boyfrien These are all descriptive words in the catego ry of defectiveness and shame. She also stated some feelings of shame regarding her weight gain. She indicated: to go buy f ood than to cook. I tire easily. I am tired most of the time. I take so much stuff Laura is determined to degree. Unfortunately her thoughts regarding her weight also show her thoughts regarding her defectiveness as she stated : She also comm ented regarding her personal disappointment and shame regarding what she perceived as a lack of accomplishment. I feel disappointed in myself that I am at this age and I have not achieved what it lly disappointed with anything but high school and that was because I had to.

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101 strengths I think thoughts about her own defectiveness are and how it controls her thinking. Laura made comments regarding family and her relat ionship with her husband that fe ll in the category of enmeshment. She also indicated that prior to meeting her husband she had been exercising regularly and had gotten her weight down to 140 pounds. However, when she started dating him there was no more going out with the girls because they were single and so it was no She struggles to see herself as separate from her husband. L aura stated she met her husband while s he lived in another part of the state and was attending school. When she met him she had broken up with her previous boyfriend and was struggling to make ends meet. Th e new boyfriend provided an extra income which lessened her economic struggle It doe s not appear that Laura has had much in the way of emotional support for most o f her life. Between her father and first boyfrien d she made a number of statements which fe ll in the area of emotional deprivation. She questions who her real father is, but she has never gotten a paternity test. She was told at a you ng age that she was to call her father. She stated: She [Mom] was sleeping with two men. She was married. But my birth ther. Because she was still married I had his last name up until I was eight. And then she moved in with my current father. When they would go off for the wee kends they would send the whole f amily over to stay with her former husband. And then when the y moved into a bigger home in a different neighborhood o ther kids to see their father.

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102 While this may also fall in the category of abuse it clearly supports the definition for emotional deprivation. Her feelings about watching her brothers and sisters play outside with their father were met with a Laura made one comment that appears to fi t in the category of insufficient self control She indicated that much of h er lack of self control revolved around her emotions and food. She stated: day long. I mean I would open up the pack and eat it all. I find it hard to just fi ght off just eating something The feelings that Laura used to describe how she felt on the days that she did not follow her plan to eat h ealthy included the words bored and disgusted. Comments she made on the food journal suggest anxiety, frustrati on and a lack of self control. Laura from an early age identified herself as having lived in an unstable environment with an abusive father Prior to her birth her mother was ha ving an affair with another man and s really is. The mother divorced the man she was married to and eventually married the man that Laura has been forced to call her father. When discussing her father she state d: They made me say he is my dad all my abusive both physically and mentally. If he was angry he wanted everyone in the house to be angry. I woul d try to hide in my room and he would literally come back there and tell me to come out of my room and sit out in the front and be around him while he was angry. When I first started gaining weight he said he would pay me a thousand dollars to loose it be cause I

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103 Mistrust and a buse was a big area of concern for Laura. She was emotionally abuse d by the man she refers to as her father and physically and emotionally abuse by her first boyfriend. Laura alluded to possible sexual abuse by this father figure, but refused to discuss this in any type of detail. She did comment that: He would call me a slut and whore and te ll me I was doing this and that and I am e look at me anymore. So that I would not be appealing to him anymore. Laura was asked whether or not her father still becomes abusive when he drinks and she encounter when the other man she had thought was her father would come to visit his ow and cry because I Laura also mentioned some incidents regarding her father which continue to leave her with a lack of trust or security around him As mentione d earlier Laura talked about her fear of abuse when her father drank. As an adult she still avoids him when he has been drinking. She stated: When he drinks I stay away from him because he becomes abusive. He is no longer physically abusive but he is me ntally abusive to whoever is around. When I was pregnant with my daughter he would try to get abusive with me again. Adding to her feelings of mistrust and abuse first boyfriend whom she dated from 14 to 21 years of age was also abusive to her When she described her first boyfriend she stated: He was one of those people that would say things that only your enemy would say like, he would call me names. He called me ugly, slut, and the B word,

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104 whatever. Anything that would come out of his m outh. He called me fat. If I gained a little weight he would say things like you are unattractive and this and that. And he worst time of my life. That is when I had enough because it was constant non stop with him. There was no escape. He would do things like not come home and then blame me for when he did get there. I was like how was it my fault. When asked what kept her in the relationship that long her response suggests that he may have feed her self esteem. She indicated that when she met him in high school he was the first boy who had ever really noticed her. She claimed in the beginning he was attentive and treated her nicely. She was caught up in the attention he paid to her and found it hard was like he would lose interest and when he did he would publicly embarrass me. We were out at a function and he poured a 64 ounce orange soda on my Laura indicated that she dealt with his abuse by avoiding her feelings creating a maladaptive schema in the category of emotional inhibition. In reference to this particular incident tend around the relationship came after she miscarr ied their child seven months into the pregnancy at which point she indicated she became numb and no longer was ab le to feel anything for him She indicated: to cry anymore. No words would come out. I had had enough. I had gotten to my breaking point and that was enough for me. Laura commen ted that she doe s not like to show her feelings: ated that food tend s

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105 to be what she turns to when attempting to inhibit her emotions. When this researcher asked if she found herself searching for a food item and not being able to identify what it No it is not foo d, but right now do what some thing to inhibit her emotions. Laura commented that she belie ved she had no one that she could talk to regarding the a busive relationship with her boyfriend showing her thoughts of being I woul d tell my mom some things but then I realized in that relationship that you forgive him your parents still remember. So I learned from that not to involve them in that. However i t is important to realize that she considered herself as socially isolated p rior to her abusive relationship with h er boyfriend lone r most of nce she was in the abusive relationship. She poin ted out that her family belief was : the home stays home and that Black women have to be stronger than that. You to anyone else to help you with your problem. myself that I am at this age and I have not ach identifying herself as a failure. When she final ly made the decision to return to school she remembered being extremely unsure about her ability to succeed She

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106 enroll ed completed anything but high school Laura also made statement s that showed that she tends to seek approval from others. At one time when she was between relationships she joined a gym with several other women gle and we wanted to terms of approval seeking behavior: When I was pudgy in middle school and no one looked at me but then I went to high school and everyone saw me. But he paid the most attention to me. He was the first person who want ed to know who I was. He was the first person to ever really open up and talk to me and want to know me. She also made the sta She recognizes this abou t herself and is currently working to make changes in this area H owever her outlook on life can simistic regarding her future. While Laura made statements t hat fit into 11 c ategories her strongest statements and areas of concern fell into defectiveness/shame, emotional inhibition, mistrust/abuse, unresolved issues with her father. By the e nd of her interview it became clear that she still holds resentment for the way he treated her as a child. She also struggles with her feelings of defectiveness/ shame, which also appear to be related to child hood and early adult memories.

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107 Margaret Margare t is a 35 year old single Black f emale. She is 5 feet 5 inches tall and currently weights 229 pounds. According the Body Mass Index this places her in the obese range for her height. Margaret heard about this research study from a friend at the universi ty and volunteered her participation. Margaret stated that her lowest and most comfortable weight is sense of failure regarding her inability to maintain that weight. Margaret identified with 10 et al., (2003) 18 maladaptive schema. Margaret lived in a single parent household through out most of her formative years. Her mother was married twi ce however each marriage ended in divorce. Based she spent a good amount of time alone starting at the age of seven because thoughts provide a sense of her feelings of abandonment: My mother was 25 when she got divorced and she was still pretty young and cute used to leave me alone a lot. She would come home from work and chec k to see if I had a bath and everything and then she would get ready and she would say remember your bedtime is 9:00 p.m., and you need to go to bed. She also talked about her first memory of feeling very alone at around age seven when she stated: After m y parents got divorced w e lived in our little apartment. M y mom had to work and I was a latch key kid and I remember it was a Christmas holiday. It was still had to work and so I am in the apartment. And I just remember feeling for the first time in my life feeling profoundly alone.

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108 Margaret does not outright express abandonment but clearly it appears she was left alone ld be co nsidered abandonment based on child welfare standards. Margaret identified one very strong memory that fits in the category of defectiveness and shame. She talked about her father being extremely abusive to her mother. Her mother was so afraid of what h er husband might do that she tried to teach Margaret at the age of five how to call on the telephone for help. She recalled: It just happened that the next time he beat her it was so severe that I just froze. I was just standing there with the phone in m I remember how he use to choke her. I remember that incident with the phone being one of the most shameful things of my life. Margaret made no other statements that fit into this category but it was clear that this is a strong area of shame that she still struggles with. watched her father abuse her mother until she was four or five years old and carries very strong memories of that time in her life. It is easy to see that the memory is strong and still an area of concern when she stated: has been very hard for me to really feel safe around people and trust them to get close with them. To connect with them. I have blanket trust issues. But maybe same kind of s ituation my mother was in. which would lead to her thought s of mistrust. She also reported that her mother mentally abused her stepfather. Margaret found that extremely p ainful to watch and on most occasions felt that it was truly undeserved. She stated

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109 My mother has a bit of an irrational temper. Like she will just start and go at it and it is a bit much. My mother would call him all kinds of names. She would talk ab out his mother and he would never push back on that. These collaborative events provide an understanding of her own statement that she clearly understands her issues of mistrusting people Margaret, by her own admission struggles with subjugation. She struggles to speak up even when she knows she has been wronged. She will withhold her own preferences and avoid making decisions and has spent much of h er life suppressing her anger. change it. I just is pretty unsatisfactory. A prime example of this was her suppression of her emotions in middle school when she was being taunted on a daily basis on the sch ool bus She w as the only African American student on the bus and found very little support from other students, the bus driver or her mother. She stated that this carries over in her life still. In her own words: I will find myself grousing to myself a bout some issue where I should have spoken up or something and/or taken it on and it is not really something I can do anything about and I will be like oh my gosh I will be thinking about it over like alcohol because I think I could really have a problem. However she indicated that she learned the skills to be more assertive in a college course but struggles to apply these skills across the board. One positive statement she made was in reference to standing up to her mother: I kind of learned that my mother is not a mind reader and so I would have to speak up for myself. This is still a work in progress for Margaret.

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110 Other issues of subjugation come with her admission of being a compliant child that it was not until she was 14 or 15 years old that she figure d ou t that she probably did s 14 or 15 when I realized that I could watch TV until about half and hour before she got home and then turn it off and the TV would be cold and that she probably compliant. At ti and felt extremely uncomfortable in their homes. Margaret again stated her compliant na ture when in the home of others. compliant person I would just like bring a book or I would pray they had some magazines and I would read magazines. I would just sit there and read a magazine and watch TV. money when she went to visit and how she felt obligated to go: nd I would just go and we would do stuff and I was expected to tr y and shake him down for stuff anyway, so I had to go and I had to kind of make an effort to at you tell your dad dy you have a class trip to go on? Did your daddy give you some money? visiting my father. It was like just get this over with. et al., (2003) definition of subjugation of e motions suggests that suppressing emotions may manifest in maladaptive symptoms such as substance abuse.

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111 if she liked alcohol she might have used that to suppress her feelings shows her ability to misuse subst ances in an attempt to suppress f I feel comfort. Oh food feels good in your stomach and it tastes good and it takes y ou out of whatever painful thing you were thinking about especially if you have to make or go get it or wait for someone to bring it to you. inhibition. Her strongest memory of using food to suppress her emotions was at age seven yea rs old. She was left home alone during a Christmas break from school. Her mother had to work and Margaret was expected to stay at home alone and entertain herself. She stated her feelings of loneliness and how she responded to them: We had some cereal a nd little snack packs of chips and some soda and some remember that it was one of the first instanc es where I did connect food with an emotion. And you know it was loneliness and tha t was my solution. I just ate. When asked if she still believes she emotionally eats angry Margaret also talked about e xperience with racial discrimination as she attended a nearly all white middle school. She was the only African American child riding the school bus and had numerous situations where she was taunted by other children on the bus. She stated: There was a p eriod in junior high where there were just a lot of racial incidents that kept happening on the school bus and I would get home and be pretty upset about it and I would eat. I would have a full meal. If there were leftovers I would eat those and then I wo uld look for something else and then I would eat dinner to t ry and cover up for the other.

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112 Margaret has carried this behavior into her adulthood and it continues to cause problems for her. When asked by th is researcher if she would consider herself a str ess eater she She commented that she does not know how to handle her emotions and stressful or hurtful times I tend to overeat and I tend to eat quite a bit of c rap. asked if she eats all the cookies Yeah. Margaret also commented on her feelings of isolation and alienation particularly during her middle and high school education. She stated: I may not have been overweight when I lo ok at it now. I went to a predominately white school and I developed early and secondly I have very different characteristics. My butt was rounder, my thighs were bigger. I look ed probably experience with being usually the only minority person or African American in a lot of school outside status and that would upset me very much because there was nothi ng I could really do about it. provided her with a sense of isolation. Margaret is very proud of her academic success however she made one comment regarding her inability to maintain a lower weight which could be considered a failure to unable to successful ly lose weight and keep her weight down it will manifest into a strong er maladaptive schema and will a ffect her future attempts to have some control over her weight gain.

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113 Margaret also made comments that suggest she has some thoughts that fall in the cat egory of u nrelenting standards. She showed some signs of being hypercritical of others when she commented : I would like to think I am not a judgmental person but I see somebody come in with French tips I make a snap judgment. And the snap judgment I make on them be and I am very attuned to that. I like, order, I like propriety, I like decency. The fact that it has not always been a value of the people around me is painful becaus Margaret made one fairly strong co mment which fit in the category of approval seeking when she talked about believ ing that she looked different than the other girls in ot concerned with how she looks. H owever she may again be suppressing these types of feelings with food. Margaret gave one example of punitive behavior regarding her relationship with her father. S he stated that they had an argument when she was about 19 years old and she stated : speak t o or hear from her father until she was 35 years old. She stated that he had a stroke and was not expected to live. Her stepmother called to let her know and Margaret made a decision to reconnect with him. However, for about 16 years she made no effort to make him a part of her life. She expresses no regret and actually suggested that reconnecting has brought new information into her life that she was not entirely prepared

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114 to handle. She discovered that she had two half brothers that were about her age which created another issue of trust regarding her father. Margaret m ade comments that fell within 10 et al., (2003) maladaptive categories. The categories where Margaret made the most comments included abandonment, defectiveness/shame, mistr ust/abuse, subjugation, feeling socially isolated, and emotional inhibition. Margaret admits that she continues to struggle with her ability to be assertive and express her thoughts and feelin gs to others. She continues to see herself as that compliant c hild who could sit quietly for hours waiting on her mother to come and pick her up. She indicated that she can become passive aggressive rather than confronting the issues just as she did when she realized she could watch television as long as she turned it off befor e her mother got home. She continues to have strong feelings of mistrust particularly regarding relationships. She indicated that she struggles to have a relationship b ecause my dad is a pretty charming guy and nice, but how can I make sur She also admitted that it was easier for her to deal with the emotional and physical abuse she endured at school with food, emotionally inhibiti ng how she truly felt about the way she was b eing treated by her classmates. Margaret lost weight several years ago because she was bordering on several serious medical concerns. Her doctor has again warned her of these health concerns, yet she continues to strugg le to keep her weight within a norm al range. Based on the maladaptive schema that were identified through her interview, it is likely that not having dealt with the issues involved may be contributing to her inability to keep her weight within normal range, even though she knows it makes h er feel better physically and removes several health risks.

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115 The four participants in the category of compulsive overeater resultin g in obesity made comments in 14 et al., (2003) maladaptive schema however all four of the participants in this cat eg ory shared comments in five categories. Each of the four participants made comments indicating thoughts and feelings in the areas of defectiveness/shame, mistrust/abuse, emotional inhibition, failure, and approval seeking behaviors. Some of the partici pants made more comments than others in each of those categories which would suggest that individually some categories triggered more maladaptive schema than others. It is important to note that all four participants discussed the use of food to inhibit e motions each indicating they found some type of comfort in food and eating. Addressing these maladaptive schema s in the treatment of compulsive overe ating resulting in obesity may provide better res ults in maintaining weight loss. Bulimia Nervosa Three w omen volunte ered for this study, each indicating they are in recovery from bulimia nervosa. Each admitted to binge eating and purging at least two times a week for more than three months which is considered the essential features of bulimia nervosa accord ing to the Diagnostic and Statistical Manual fo r Mental Disorders (DSM IV TR; American Psychiatric Association, 2000). Each indicated that they would eat larger amounts of food, experiencing a sense of lack of control during a discrete period of time. Al l three women admitted to self induced vomiting after a binge. All three women indicated they are currently in recovery The least is two years and the longest is 15 years. As each tells her story it is clear that they are still struggling with some m aladaptive schema for which each has found a different way to cope. Donna works a

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116 12 step program and shows the strongest s igns of recovery. Carla appeared to use food as comfort and currently, based on the body mass index is obese Jade admits to cont inuing to binge on specific foods but denies vomiting. Each of their stories identified maladaptive schema which still may be disruptive to their recovery process Donna Donna is a 25 year old Caucasian female. She is single, but engaged to be married. This will be her first marriage. She has no children. Donna stated that her binging and purging behaviors began at 16 years of age and continued until she was 23 years old. Her story is complicated by the fact that she is also a recovering drug addict Her b ulimia started at age 16; however, she started using marijuana at 14 years of age. She stated that when she could no longer get access to drugs she switched to binging and purging in an effort to continue to inhibit ent four months drug abuse but failed to consider her eating disorder in her e arly recovery. Later she did start to apply a 12 step program to her eating disorder as well As she stated : I would have periods of abstinence and I would work the 12 step program and apply it to my bulimia and then I would have relapses where I would b inge and I was doing it, and it became premeditated. Everyone of them. And I would s pend lots of money on what I was putting in and throwing up. D o lcoholic who has been in recovery for 20 years. She believes he r mother had difficulties with a norexia although there was no clear diagnosis. Her perception of her mother now is that she may be an active alcoholic. Donna stated she has never received p rofessional treatment for her bulimia although she

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117 indicated that she applies her 12 step recovery program to both her addiction and bulimia et a l ., (2003) 18 maladaptive schema. Donna be lieves that when her father became sober this was the first time she felt ab andoned. In her words : for the kids until they got divorced and then he knew we were the only family h e had really have a lot of time to think about us kids because he was trying to hold on to the marriage Donna indicated that at one point neither one of her parents was abl e to manage her behavior which left her feeling abandoned. My mother sent me to live with my father. I was 15 and I stayed there for four was me in the teen crisis shelter. Donna admit t ed attention more than everyone else because everyone else will just give it to me and she Her approval seeking behaviors le ad her to ru n ning away from home. When her mother made no effort to bring her home she again fe lt abandoned. Donna My mother said you do whatever you want. You think you are grown up you do what you want a nd just stay there. And then six hours later the cops came and picked me up because she changed her mind. So I went to juvey and they called offense. And my mom said I am no t coming to get her. They said then we consider that child abandonment and they turned me over to child protective services. When asked which of her parents she would consider to be more unstable Donna stated y had at the time. My father has the

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118 standing record today for being pretty stable. My mother has the record for being issues related to her own behavior in the end her p erception that her paren ts abandoned her seemed clear. Donna made numerous comments regarding her thoughts of defectiveness and shame associated with her eating disorder and addiction in general lots of obsessive compulsive and self ce part of my body. She made comments about her own frustration with herself and her use of food to attem pt to make he rself feel better: me. There is no reason to try and help myself because I will always be just this In her recover y Donna has begun to work on her feelings of defectiveness and shame and made several comments tha t show how she works her program : I have to practice at being somebody that I want t o be and I think it was six months ago that I finally started to feel really successful at this. Practicing being someone that I wanted to be and I started to feel a lot of th ese feelings of esteem. to loath myself but now I see myself as more of a quirky you know traits I still need to work on to be of know what I think and that is okay and I will just have to learn more politeness. I have already been learning more politeness and this is a ctually okay that I can this hatred for myself and now it has just changed. Donna is working hard on her recovery and is making progress particularly in forgiving herself and building her self esteem This provides her with less of a sense of being defective.

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1 19 Donna made comments regarding emotional deprivation that appear to stem from her relationship with her mother. Donna believes now that her mother was doing t he best she could but when Donna was growing up she believed : She did not have the ability to talk things out which is what I really would have you hin gs that make us feel good tha n just would just try to control. And when she could not control me she would ignore me. ion and be all up in her face and she would completely ignore me. Donna admit t ed that her inability to deal with her issues with her mother led to was going on any ot She talked about her binging and purging behaviors and her lack of control over stopping herself once she started She stated: myself. I really loved to do it and I find it difficult to control myself at times and so I think it is both things. I would like to tell myself I was eating too little and my body revolted and I have to put more food in but it is also that I have less c was like a compulsion. It was like I wanted to use a four letter word but screw it. You know. It is kind of a familiar thing in my stream of consciousness where it goes. I don more I am just going to do it. When asked what she thought she gained from binging and purging she indicated: Her issu es of self control played a big role in her inability to give up her binge/purge behaviors when she entered a recovery program for her drug addiction. In e ffect she simply traded one addictive behavior for another.

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120 ema is mistrust/abuse. This is the maladaptive schema where the majority of her statements appear. Many of her issues w ith mistrust/abuse also stem from her relationship with her mother. At age two years her mother apparently was caught physically abusi ng her y dad found out that my but her father told her about it. Donna states that she was surprised by what her father told her t on my fourth step yet and it messed me up in the head for a er mother remarried and her stepfather was also an abusive person. She was 13 years old and this became the start of ther started hitting my younger sister and I still smoking pot and used for two years. When she no longer had access to drugs she began binging and purging. In refer ence to mistrust, w hen asked to describe her mother d : I think she can twist and change the truth in her own mind. She is not an honest woman. I would trust her with my physical well being to a point. Because if I go on a trip with her and it is just her and me and she is drinking and upset, then I reason with a crazy person? Donna also noted when her mother joined a recovery program for her own eating disorder d I showed signs of over eating nd abuse. were constantly trying to maintain some type of control over her. Her perspective on their need to control

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121 would take my life away. They would take the little jar t hat is me and turn it upside stepfather was most responsible for attempt ing to control her beh avior. My right to control myself had been removed. He was manipulative d their self control. do to try and place some controls around her. At some point th e binging and purging apparently was not enough and she started cutting in order to control or release feelings. She was in a treatment center at the time and interestingly reported the cutting to the therapist but did not report that she was also bi ngi ng and purging her meals Prior to being placed in a treatment facility more than one occasion. When her parents became frustrated Donna ended up in a teen comments described her need to inhibit her emotions in order to survive : W hen your parents are kicking you out it is like this resignation would be a lot of how I would feel. I would get this numb I would describe kind of like a PTSD type response. I had no feeling. The underlyin g feeling I was trying to suppress was having to deal with my body and accepting my body and myself. Donna also expressed thoughts which indicate her unrelenting standards for herself. Early in the interview when asked to describe herself one comment she made y another point in the interview she talked about an effort on her part to control her calorie at rigid black and

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122 asked what would happen if she went over the 1350 calories in a day and her response was simple and matter of fact something and then realize it was a mistake and I would have to make myself throw it she re calls trying to gain her else will just give it to me and she made me beg for it rly that her need to feel loved revolved around food. She believes that her mother saw her as having a tendency to be over weight and therefore controlled her food intake and what she w as allowed to eat. She stated ld goad her at times to tell relation ships in her life. She commented: that people like me if I do this then I Donna also made one very strong punitive statement regarding her mother. When she finally got to a point where she r ealized that she may never be able to have a positive relationship with her mother she came to the conclusion that she would need to exclude rejected her as a punishment a nd as a way of dealing with the rejection of myself from

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123 Donna made comme et al., (2003) categories of maladaptive schema. She is now in recovery for her drug addiction as well as her bulimia. She works a 12 step pr ogram for both. She works the steps of the program with her sponsor and recognizes that she is always just one drug or one binge away from relapse. She also applies this program to her bulimia. She recognizes that she has a life long struggle and appear s to be working hard to change the things she can while accepting those things she cannot change. This has served her well and she made clear statements that allowed this researcher to see that she is working through her maladaptive schema in this process Particularly in the area of defectiveness and shame she appears to have a better understa nding of who she is. She stated that she tends to be over confrontational in her style and that she is trying to stop confronting people so much. She commented: Yes I have always hated myself for that and then recently it is just you know what I know what I think and that is okay and I will just have to learn more politeness. I have already been learning about politeness and this is actually okay that I can incorp orate this into my confidence and my idea of myself. myself as more of quirky, you know progress for Donn a as she stated : f the self Jade Jade is a 27 year old single Hispanic student who fits the DSM IV TR ( American Psychiatric Association, 2000) diagnosis of bulimia nervosa. She indicated she s tarted binging and purging at the age of 16 and stopped two years ago. Jade was referred to the

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124 study by a counselor. Jade attended group meetings and 12 step programs off and on for approximately 5 years seeking help for her bulimic behavior. Jade was born in the United States ; however, her parents entered the country illegally. Shortly after her birth, they returned to Mexico. She lived in Mexico until the age of nine with her mother, father and brother at which time her parents gained legal access in to the United States. She returned to the U.S. with her parents at age nine. Her older brother had to stay in Mexico because they could not get his paperwork in order. Jade indicated that she struggled to fit in either as an American or a Hispanic. I was not good enough for either. The older I got the more my mom pointed out that I was getting too involved in the American life style and I was denying my successful I was. Th is is a clear sign of her feelings regarding her defectiveness and shame. Her parents were migrant workers which required that they moved often and she struggled with friendships This left her feeling lonely and socially isolated. She also believes tha t she was constantly compared to a cousin who was the same age but was always smaller in stature. She felt unaccepted by family and friends again leav ing her to feel defective Her bulimia ori ginally appeared to stem from her approval seeking behavior to uses food as an emotional crutch and occa sionally binge eats. She stated her favorite binge food currently is cereal S he appeared to believe this is a healthy alternative to

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125 what she used in the past as binge foods. Jade made comme nts that fit into 12 of et al., (2003) maladaptive schema categories. Jade stated that she believed while growing up in Mexico she had a relatively normal childhood. She had friends, attended school and remembers this as being one of the happier times in her life. However, once her parents were able to secure green cards and return to the U.S. Jade began to see a change. Both parents worked as migrant workers throughout the southeast Jade on is that because of their work they had very little time to spend with her. Because she could not speak the language she felt alone, after I graduated. Once we did, they decided not to stay and so I was left alone. For those nine months I was pretty much living on my own. returning to Mexico however the e nd result was a sense of loneliness and abandonment cope with it any other way. ffort to relieve her emotions. One area of maladaptive schema which appears to have had a big impact on Jade throughout her childhood that fall within this category. Jade struggled with thoughts about not fitting in. S he indicated that when she tried to fit into Ameri can culture her mother complained that she wa s giving up her Hispanic heritage Y et at the same time

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126 when s he tried to embra ce her Hispanic side she did not believe she was ever able to do it well enough to please her family. She stated: American. I was like not good enough for either one. I felt that anyway. The older I got the more my mother pointed out that I was getting to o involved in the true but the more I tried to be Hispanic the less suc cessful I was. Jade believed that the comparisons the families made between her and her cousin suggested that she was not good enough. This again p ointed to her feelings of defective ness : I was not a very popular kid. Not only that, but when I was growi ng up, I was person. Like really, really tiny. So the comparisons were always that I was a little heavier better than me in that way Jade also commented on her feelings of shame and guilt after a binge and purge episode: there is like a high that you get. Because you are relieved but i t is like well I just got rid of something that was not suppose to be there. And then it lasts for a good five or in my mind I think that it has to do with concerns like being able to control the thoughts that go in. It is like you wake up with problems that are going around the house or feelings of inadequacy that I am not good enough so I am just going to make you fat. So not only do I not feel good this is only going to make you fat. Jade also made several general comments about her thoughts of defectiveness and d one nothing with your life. You are not successful and that is why no one wants you. behaviors and the fact that she knew what she was doing was not appropriate or healthy

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127 S A good sign of recovery is Jade about her perceived defects. She did tell her mother about her eating disorder after she had stopped binging and purging. She realized: I guess expectations of me being the excellent daughter has always been there and sometimes it is just like, you know what I am just human. I need help and other things too. I am their only daughter and you know what it is just like sometimes I know it is like I told my mom you are thinking that I have it all put together but I and I need for you to understand tha t I am just as human as anybody else. An excellent beginning to accepting herself and allowing her mo ther to see who she really is. Jade admits that she has a problem with decision making which likely stems from her having to make decisions while living on her own in Mexico at 17 years of age At hat even applies now. I am still struggling with that, and what everybody Jade also made two statements that fit into the category of emotional deprivation. In parti cular she believes that her father was unable to provide her with a sense of ca re and belonging. She described her father as very distant. lives in his own world. So it is like, it is about him.

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128 She expressed a lack of support from both parents throughout her life adding to her sense of loneliness and feeling emotional ly deprived as she stated someone I could rely on like my dad to protect m Jade expressed a belief that her mother had anore xia nervosa; however she was never diagnosed Jade believed her mother depended on her for support Her enmeshment with her mother was identified when Jade i ndicated that one of her fears was not being able to have a life of her own due to her her. After consulting the list of words and phrases offered to her she described her relationship Jade has a sense of responsibility toward her m other where she believes that it is her job to fix her my mother. She is such a caring person yet at the same time she is so fragile that I want While her relationship wi th her mother shows signs of enmeshment at the same time she expressed her mistrust as to how her mother might perceive her help. Yet at the same time she has this powerful charac ter and personality that is manipulative at the same time that if you get too close to her she will make your help her Jade also expressed feelings of mistrust regarding the m parents always told me we would go back to Mexico and so I thought in my mind that I always wanted to go back and it seemed like a lot of broken promises because we never H owever he r mother and father decided not to stay there and returned to the United States leaving Jade in Mexico to take care of

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129 herself. During this time her feelings of isolation were overwhelming and her binging and purgin g increased. She commented: eel like I could trust anybody to go Jade also expressed that her help. She stated that she believes her fa ther has her on a pedestal and that she is unclear what would happen if he found out she was not who he believed her to be. A s she stated : While living in Mexico on her own Jade ating disorder became more out of control, yet it provided her with a sense of control for her emotions particularly her Jade also expressed that com ing to this country as a young child also carried a strong sense of isolation for her. you never have fri anyone becau se Jade also appears to be very self sacrificing. Included in her enmeshment with her mother is Jade of he r no one else would. She stated : My dad was working all the time and so it all came down to me. I was forced to feel good, I had to keep her happy. And f or a kid that is kind of hard. Jade still carries this need to place others befo re her own needs as she explained coping mechanism is stop feeling sorry for yourself and see what you can do for e this may be a sign of recovery at the

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130 need to help others keeps her from working on her own issues This may be leaving her open to relapse. Jade As she st ated: It was one of those things you do to try and compensate the feeling and you over eat so much in such a short period of time then the guilt that I over ate too much when I am li ttle you hav e to get rid of it right away. At times in her life when she b ecame overly stressed she stated : I would eat, and eat, and eat and then just get rid of it again. There was a lot of s eating is going to make me feel better, and um, it was just a coping mechanism because I was so stressed out that I would eat and then just keep eating and eating and eating and od. During her time in Mexico she found herself trying to cope with her feelings of loneliness again by binging and purging as she stated: So I was in Mexico by myself so I was dealing with being lonely. I was very the I will you. Jade believes that her family perceives her as being independent and very successful H owever she does not see hers elf in the same way. She stated that she has provide herself with encouragement that she ca n succeed she stated voice will come out and says no Jade includes her issues of enmeshment with her mother and her efforts to help her as she

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131 er Going along with her fear of failure, Jade expressed unrelenting standards for her over ac think I am doing enough. She also indicated that some of her approval seeking behaviors will end up in her setting up nobo dy likes me, then I am going to torture myself so that I talked about how her need to be the perfect daughter influences her perfectionism: I think again I always try to keep the faith that I was the perfect kid who never did a nyt hing wrong. And as an adult I still want to keep the thing that I never make a mom voice and dad voice because my dad al ways thought I was super smart. Jade has started to realize in her recovery that these unrelenting standards do not help her eating disorder and she is work ing to make changes. She stated : There is a little voice somewhere in the back of my head that is just an over achiever and it is like you are not going to ge It appears that many of Jade perception of not fitting in. This appears to start with her moving to the Unit ed States at the age of nine years old and not being able to speak the language. Even afte r learning English she continued to struggle with seeing herself as a part of something, particularly when her mother is critical of her Americanization. This seems to culminate in her belief that she is being compared to a cousin of the same age who is smaller in stature than

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132 Jade Her expression s regarding approval seeking appear to culminate in her need to fit in and be accepted particularly by family: If I can be accepted any other way the n at least if I stay little that will be the way mind again as I got older I was like well, if I can stay this little everyone is going to like me mor losing a little bit of weight that I would be accepted and then it becomes sort of like a circle. Because people say you look good, so then you want to continue to do it. much that you want to do it but you do it more, and more, and make me accepted. Jade struggle While Jade et al., (2003) 18 maladaptive schema t w o areas that appear to have the strongest statements are the areas of defectiveness/shame and approval seeking Jade source of concern and could lead to relapse if not considered as part of her treatment program. Jade has sough t out 12 step recovery programs f or support. She has attended meetings but not worked the steps which are considered key to a successful r ecovery. Because she admits to occasional binge behavio r without purging and justified this with the food she choos es for those binges she should be considered vulnerable to relapse. She failed to return her food journal. Reviewing the journal might have provided more information regarding the binge behavior and what thoughts and feelings continued to be linked to t hose binges.

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133 Carla Carla is a 40 year old married Caucasian female. She is a graduate student at the university where she heard about this study in class and volunteered her participation. Carla stated that she started binging a nd purging during high sc hool. I could tell the calorie count of everything and what one quarter of the calorie content of anything was. I would get up before school and exer cise. I played volleyball and we would practice after school and then I would go home and exercise some m try and throw up. I would just get sick. Carla s tated that this went on for about five or six years. She stat ed I would get not seek treatment for her bulimia. At 24 years of age she joined the Army and then did a stint with the National Guard. She stated she st opped binging and purging because she was convinced that it would get her discharged. She stated she has not binged and purged in about 16 years, however admitted that she still binge eats when her emotions are out of control which could indicate that sh e is not fully in recovery Carla made statements in 10 et al., (2003) categories of maladaptive schema. Carla stated that her mother has been an alcoholic for as long as she can remember. She stated that her mother was promiscuous and Carla was the product of a mother did marry when Carla was about five years old S he was raised by her stepfather until she graduated from high school Her issues of aban donment are related t o her Florida and actually left me with my step

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134 the conversation without the use of the words and ph rases list described her mother as Both words fall in the category of abandonment on et al., (2003) definitions of maladaptive schema. She state d that through out her early adult life s he continued to struggle wit the feelin Carla appears to have a good self concept and therefore made minimal statements that would fall in the category of defectiveness and shame. One area of concern for Carla has be en the affect of family on her marriage. The turmoil surrounding h er previous their lives at times would affect her relationship with her husband and their ability to be close to each other. Because of the turmoil their sexual relationship has always suffered and as she stated: so then I feel When she married she also gained an 11 year old step daughter. Her husband had been given custody of the child by the court. The step daughter immedi ately came to live with them. Carla stated there was a lot of turmoil regarding her step daughter, her husband and his ex wife and this caused some difficulties for them. After the step daughter graduated high schoo l she decided to go live with her mother in another state. Carla sometimes questions her parenting skills She stated that she has learned things about parenting through her education that she wish ed I think about it I feel g uilty indicating her guilt r egarding her ability to parent a ffectively. otional deprivation. She stated that even when she was living with her mother and step father her relationship with her mot her was not strong. She recalled spending an enormous amount of time at her

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135 mat maternal grandmother as being affectionate to her and perhaps the reason she has However, according to what one aunt has said, her grandmother was not a great parent to her own children. She stated her grandmother found her own father after he hanged himself in the b arn when s he wa s 13 years old. After her grandm other married and had five children her o perception of this relationship identified generational emot ional deprivation as she recalled : really th ty to be a good parent as well. Carla also described her stepfather as not a good parent. She indicated that he spanked her a couple of times and raised some w elts but she does not see him as being physically abusive to her. She did indicate however that he had a bad temper and generally yelled was more like a person t tifying emotional deprivation. Carla had not been in contact with her mother for several years prior to becoming engaged to be marrie g the wedding. Since that time their relationship has not been positive. Carla stills ection toward her. She commented : I noti ce that even when I got into school she says that she is proud of me and I think that she is not proud of me but more like my daughter is a graduate student type thing, not really me. And I would tell her like real things and she is not even

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136 listening. S intense and she would be like yeah, I ordered these new whatever that I saw in a magazine and I hope they work out. C arla stated that her relationship with her mother is not good. Th e mother has moved in and lived with her and her husband at least three separate times since they have been married over 12 years ime has finally moved into a trailer park and is living on and while her mother was not a good parent s, et al., (2003) category of enmeshment. She stated: I ha ve been the parent in the relationship for a lot of years. And I have always, out of a sense of obligation l ook at it Carla appeared to have a strong sense of obligation to family which culminates into enmeshment with her mother After her mother received her first driving under the influence citation she continued to drink while living with Carla and her husband. They became concerned that if she continued to drive she was likely to get hurt or hurt someone else. T hey call ed a friend vehicl e where she was likely t o be headed, and that she needed to be pulled over. Carla Her mother was arrested a second time and again Carla bailed her out and took her home. Carla stated that the relationship between her husband and her mother deteriorated over

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137 Carla appeared to constantly sacrifice her self in her relationships wit h family and eventually realized that she is g iving more of herself than she is receiving back from those she supports. At that point she becomes frustrated and starts to have thoughts of entitlement. This appears to become an issue particularl y with her husband as she stated : At the point where I w as ready to leave him I said look I opened your business store, I struggled with two electric bills, two phone bills, I mean I did everything. I mean I managed the store and the household and I raised your daughter. I said I gave you 10 years now I am go ing to school. It is going to be harder for me to go to school if I leave you so like it or not you are going to be stuck with me until I finish school. Carla stated that since she has started school they have made an effort to work on their relationship there and I multiple people primarily an older step brother, a cousin; my step sister did a couple of things of the house Carla stopped trying to gain weight and her symptoms of bulimia nervosa began. Carla also commented that she liked going to her maternal because the step siblings were not invited and she found it to be a safe place. In her hurt me there. Carla talked some about how the sexual abuse has affected her thou ghts regarding her physical appearance when she stated:

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138 identifying her lack of trust regarding relationships Carla also feels some mistrust and emot ional abuse when she talks about her relationship with her stepdaughter. Carla stated that she raised her stepdaughter from the age of 11 years old. When she turned 18 the step daughter dismissed Carla by moving back to live with her own drug addicted m other. This hurt Carla tremendously. She believes she gave so much of her time to this young woman and then was rejecte d for her efforts. She stated: is all my fault. when I think about it. When asked what Carla saw as her own strengths her comment appeared to fit in the area y for me to not While she sees this as a strength it appears to stem from her issues of mistrust. Carla grew up not knowing who her biological father was. Base d on the few things she was able to find out from her moth er she believed she was the product of a one night stand. Prior to getting married Carla decided she wanted to find her father. She asked her mother for information and she provide d her with a name. Carla set ou t to find this man and her stepfather off ered to help. When her mother found out the stepfather was helping she told Carla she had lied about the name and that she really w who her father was. This provided Carla with many concerns regarding her ability to trust her mother, as she sta

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139 Carla appeared to be very self sacrificing and over accommodating particularly with family. She struggles to set boundaries and is easily taken advantage of. One of et al., (2003) areas of maladaptive schema is self sacrifice defined as excessive sacrificed my whole life When she agreed to marry her husband she was aware that she would also be gaining a stepdaughter. Within a few weeks of the marriage she began to feel like perhaps she had made a mistake but she stayed anyway telling her husband : m not going to leave you until your daughter graduates from high responsible when I make a commitment and really just for her I felt like I had made that commitment and I owed her that because it is not her fault who She was more than willing to take on the responsibility However, the stepdaughter went through some rough times prior to coming to live with Carla and her husband D ue to that they struggled t o have a positive relationship with her. Carla was very hurt when her stepdaughter decided to move to another state at the age of 18 to live with her birth mother, but willingly allowed her to return after two years and live with them again. She was out t here for a couple of years and then she called and said I want to come home and go back to school. She was engaged so we said that is fine and so we got her back, her fianc, and her little dog which I ended up being stuck with. I said you can come back h ome and live at home but they were both lazy, sloppy and dirty. Carla provided another example of her over enmeshment and self sacrificing when sh e talked about her youngest half brother. At the time he was still living at home his biological father was in another state. She indicated that the

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140 half brother called her one day very distraught and threatening to commit suicide. Carla stated : He told me he wanted to kill himself and he told me how he was going to do it and it frea ked me out and so I begged him I will come see you, just promise me my jobs and I drove home and told my step do anything. While she co uld have easily picked up the phone and cal led other relatives who lived near the half brother or her stepfather and report her concerns she was compelled to drop everything to run to his aid showing her need to sacrifice self for others. Carla made stat ements that showed her emotional inhibition. When talking about her mother and the issues that the y have been through she commented : their relationship now is one of her mother calling if she n e eds something and Carla providing what she can. She indicated that she had an argument at one time with one of her aunts regarding her responsibility to her mother. The aunt suggested that Carla needed to be doing more and that Carla had a responsibilit y to let her mother live with her for as long as she needed or to give her : barely make ends meet. I am a student. How dare you complain about taking care of my grandmother interviewer she commented : also co mmented on her marriage and indicated that she believes she and her husband may

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141 a dish of ice cream at night or we will bond over food, popcorn, and a movie instead of sex with food Carla responded : Carla made some comments connected to her marriage and her step daughter that fit in the category of failu guilty because looking back I have learned some things and I think there were so many : also talked about her unrelenting standards in relationship to her marriage and her bulimia. Regarding her husband she stated : too much from him a s far as how I think our relationship should be and how I think the her bulimia nervosa indicating: Once I started to loose weight it was like an addictive quality that I wanted to lose have control of it. Throughout the course of her interview Carl a made comments that fi t into 10 of et al., (2003) 18 categories of maladaptive schema. Those areas with the largest number of statements may be the areas that should be targeted for treatment purposes as categories needing improvement. For Carla there were four categ ories which stood o ut as possible areas of concern: self sacrifice, emotional deprivation, mistrust/abuse, and her unrelenting standards. The mistrust/abuse is related to unresolved issues regarding her lack of trust regarding her mother. Another area of concern is her ability to self sacrifice,

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142 been under control for many years it is likely that lack of resolution in these areas is keeping her from being able to ma int ain a stable healthy weight. et al., (2003) categories of maladaptive schema the participants who fell in the category of bulimia nervosa made comments in 1 6 of those categories. They shared comments in six of the sixteen categories including a bandonment, defectiveness/shame, emotional deprivation, mistrust/abuse, emotional inhibition, and unrelenting standards. The number of comments in each of those categories varied but because each of the participants did make comments in those categories a treatment plan could include addressing these maladaptive schema in a group setting This could lead to a reduction in the relapse rate for bulimia nervosa. Anorexia Nervosa Three women volunteered as participants who fit the DSM IV TR ( American Psych iatric Association, 2000) criteria for anorexia nervosa. Each of the participants at one time maintained a body weight that would be considered less than 85% of what would be expected for a female of the same height and age. Each admitted to a fear of we ight gain or being fat and a denial of the seriousness of their weight prior to recove ry. Each of the women indicated that she is in recovery One participant, Jillian continues to struggle and has relapsed several times in the past three years. Her we ight continues to fluctuate between 115 and less than 100 pounds. However, over the course of the past year she has successfully kept her weight above 100 pounds. Monica has been in recovery for six years, but still counts calories and watches her weight She has successfully maintained her weight between 105 110 pounds over the past six years.

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143 Andrea has been in recovery for 18 years. Currently her weight is in the overweight range based on the Body Mass Index. She admits that she now finds comfort i n food S he eats and then feels guilty and then she tends to not eat the next day which would suggest that the behavior and thought processes that accompanied her anorexia are still low. Jillian Jillian is a 24 year old female diagnose d with Anorexia Nervosa. She has recently married and has no children. Jillian was referred to this study by a counselor. Jillian stated that she started restricting at around the age 12 years and wa s diagnosed with anorexia at the age of 15 years. The diagnosis came during her first hospitalization. Her parents became concerned when she appeared to be grossly under weight. Upon admission to the hospital she weighed about 80 pounds. She stated she was only treated for physical issues such as de hydration and mal nutrition during her hospital stay and she was forced to eat and gain some weight. Once she gained a few pounds and appeared to be eating she was released by the hospital back to her paren ts care and referred to counseling. She has been hospitalized on four occasions. The second time she was hospitalized she was very ill H owever she fail ed to see the relationship between her eating disorder and that her body was most likely reacting to lack of nutrition. She stated during her second hospitalization she was at her lowest weight of 77 pounds. She had a problem with her liver and she was only treated for the physical ailments. Her eating disorder was not addressed. The third time she w as admitted to the hospital it was afte r an attempted suicide. She dra nk about an ounce of Cool Aide mixed with bleach. The fourth tim e was again due to her body reacting to the abuse of her eating behaviors. She

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144 stated that her electrolytes and potassi um were at critically low levels. She was again only treated for the physical issues and released. After being released from the hospital the fourth time, she sought counseling on her own. She has had three different counselors working specifically with her on her eating disorder. She stated that the first time was after her first hospitalization. She was not ready or willing to change her behavior and the counselor ended up confronting her with that. The counselor asked her to come back to treatment when she was ready to really work. The second time she sought counseling she was 21 years of age and this time she stated she was asking for help. She believes she made progress with the second counselor and continued to see her for approximately two yea rs. She stated that she seemed to come to a point where she was no longer progressing and actually back sliding. She and the counselor agreed it was time for her to find another approach. She is now working with the third counselor and stated that it is early but she feels like she is making progress once again. She currently weighs 115 pounds which is within normal range for her height according to the Body Mass Index. Jillian stated she does not believe she i s anorexic anymore. H owever, her sample f ood journal suggests that while she does not completely restrict her food intake, she has extreme limits and barely eats enough calories et al., (2003) 18 maladaptive schemas as reviewed below. Jillian sees herself as defective and made several statements in this regard. When asked to describe herself the first response was: I despise myself. A color that comes to mind is very black, very angry black. I hate the way I look because of t hard t o say nice things about myself.

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145 She also stated that she was not very social in school and still struggles with friendships. accept mentioned I was into a lot of stuff that I wish I ha Jillian described her father as extremely controlling. He sold his business wh en Jillian was 12 and became a stay at home dad. He took control of the entire household. He cooked, cleaned and did all the grocery shopping. He also managed the finances. He controlled his family by not allowing them to make decisions or pur chase any type of items without his approval. For an example, all the family vehicles are in his name only. Each of his children is purchasing one of the vehicles from him rather than getting a loan on their own or co signed with a family member. If th ere is a problem with the vehicle he is the only person who can determine where the car can be taken for and his need to is likely to be a contributing factor. When asked ntrolling behavior she stated: It helped me have control over my life. He could threaten to take anything away from me but I could care less because this was one thing he could not control. I with me. into her feelings of dependence and incompetenc e. She displayed this in the following remarks: myself a lot due to the things that have been said by him. I fear decision making.

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146 allow my partners to mak e all the important decisions. ization her father and her fianc decided that she n with her fianc. She stated: I knew nothing about moving until the day I was getting released. My fianc told me on the telephone that he and dad had a chat. I was freaking out and had a panic attack in the hospital. It is weird because I know I can make my own While she tends to show resentment for this decision she was compliant and continues to allow her husband to do most of the decision making. Jillian also made statements regarding emotional deprivation in reference to her father. When provided with the list of w ords and phrases to help her describe her father provide her with emotional support. This also leads to her statements regarding emotional inhibition. She indicated tha t she would attempt to hide her feelings from her father because she anticipated that his response would most likely be angry and he would say hurtful things to her. At around the age of 18 years Jillian began to find it more difficult to hide her restri cted eating habits and was forced to eat. In order to maintain control she began to purge her food. When forced to sit down to a family meal she would eat and then excuse herself to vomit the meal back out. Eventually this became another way for her to d to binge, purge, began relying She also stated that when her favorite aunt died of ca ncer she was unable to about that. I used my

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147 eating disorder to control my emotions. She also comme nted about emotional inhibition during her middle I think a lot I was just numb. carried into adulthood and she now inhibits her emotions by binging and purging. ry day. I still share eparating and Jillian recalls: my parents and I would consistently hear from my mom what my dad was doing and consistently hear from my dad what my mom was doing and it was constantly anybody else She also commented that in every relationship she has ever been in she tends to take on the personality of the person she is with. She stated : I have a lack of separate identity. With him he listened to country music so I identity. I am working on it. I kind of lose it and then I get stuck into it and then I start feeling miserable, and I am like why am I feeling and I figure out oh I am acting like what the other person i s acting like and I gotta get out of there. She struggles to find and express her own personality within any relationship whether it is one with her parents or friends. Jillian also expressed statements that make it clear that she has a problem with bein g able to exercise sufficient self control. She is easily directed by impulsive b ehavior. I start saying I gotta do this I gotta do this and immediately it starts and it is right there and there is no stopping me. A couple of instances I have dissociated during the day and ended up in places where I have no idea how I got there. It is kind of is like some days I am good kno w it just gets to me.

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148 Jillian expressed very clearly that she has issues of mistrust and abuse, particularly surrounding her relationship with her father. While her father was not physically abusive, comments she made regarding him would support emotiona l abuse. The time I spend with him now is all in need to spend time with her father, but she does it by going grocery sho pping with him This establishes a time limit and he will be concentrating on what he needs to buy and not be able to focus on a conversation with her. She also commented on a relationship with her first serious boyfriend in term s of mistrust when she st ated: My first boyfriend ...was my first everything and he kind of took advantage of my naiveness. He took advantage of me in lots of ways. The way he was treating me I did not feel was matching what he was saying. She continued her statements of mistru people because I know I will get w o r get a what you Jillian also expressed feeling social ly isolated. She commented that she sees herself as different from other people. Neither she nor her parents seem to fit into any When discussing her personal issues of social isolation she Jillian commented several times throughout the interview regarding her perception of her own failure. When asked if any of the words from the list applied to

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149 her hesitation. During a post interview when asked if she believed that this was still an adequate desc that she struggles to complete things. When asked to elaborate she mentioned that she started taking piano lesson s and quit and then started playing soft ball and quit. Her per ception of quitting these things is that she failed rather than perhaps they were not what she wanted to do after she tried and made a decision to stop. When asked if she has been told by someone that she was a failure for quitt ing she mentioned her fath er. Jillian also displays unrelenting standards for herself and can be hypercritical regarding her outcomes. She described herself stating I am driven. Yes very driven and compulsive. When I set my mind to something I do get it done. Sometimes I will sacrifice everything physically and mentally w During middle school she joined the cross country running team. Her coach challenged the students to run more than he did over the summer. Jillian stated : You are looking go od. You are running really fast and I was pushed to even do better than that. And so of course I wanted to succeed and thought losing a few pounds although I had lost a few running so the more I ran the more I lost. So at igh. I was number one on the team. Compliments still were coming because I continued to lose weight and that summer after cross country and track my coach challenged me to run more than he did. I took that way to the max, over 500 miles that summer and t hat is when I ended up in the hospital. Jillian also found herself placing excessive emphasis on gaining approval particularly at school, as she commented : I went to a small school and I had trouble with rel ationships and stuff, not really fitting

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150 that when she started running she started to recei ve compliments on looking good and being the best runner on the team T his encouraged her to run more. Out of the 12 categories of maladap tive schema that were coded for Jillian seven categories stood out. For example she only made one comment that clearly fit in the category of self sacrificing behavior statements in the area of mistrust/abuse. Th e four categories which held the highest number of statements included insufficient self control, mistrust/abuse, emotional inhibition, and unrelenting standards. While she did not make as many statements in the categories of defectiveness/shame, depende nce / incompetence and enmeshment the statements she did make tended to be very strong and self critical and may be affecting her ability to stay in recovery. Monica Monica is a 29 year old Caucasian female who was diagnosed with anorex ia nervosa at 17 year s of age. Currently she is married with no children. She learned about the study from classmates and volunteered to participate. She states she was never hospitalized for her disorder however she originally met with a psychologist at a ital in her home town. She saw him for 10 sessions and all she remembers of those sessions was sitting in an unpleasant office and crying. After the 10 sessions the doctor told her mother that Monica was wasting his time as she did not want to talk about her issues and he quit seeing her. She was then seen by another doctor and also saw a dietician at the same time. The dietician indicated to her that she was storing fat by eating potatoes, one of the few items she would eat, and therefore Monica stopp ed eating

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151 potatoes. A third attempt at counseling included t he entire family which Monica stated was not helpful either and treatm ent attempts stopped Monica mana ged to maintain her weight slightly above 100 pounds during the rest of her senior year in h igh school. When she graduated and went to college in another town she again stopped eating and her weight returned to below normal range. She saw her local doctor who referred her to a dietician. Monica stated this dietician was the most helpful person sophomore year when she was pledging to a sorority. During her sophomore summer she went to a summe r program which she states changed her life. While the program was not associated with her eating disorder she stated that it provided her with the guidance that she needed to make better decisions in her life. She stated she has been in continuous recov ery for nine years. Even with her continued recovery, Monica made statements that fit into s ix et al., (2003) 18 maladaptive schema. Some of her comments relate to her past thoughts and behaviors H owever, some continue to be areas of concern and could lead to relapse if not addressed. hip with her mother. She stated that her mother was always quick to judge and very demanding as to how things should be done. This eff her own defectiveness She described her mother and their relationship as: Hello, she is a control freak. I would get into trouble for putting a spoon in the wrong drawer. And we probably did it multiple times. But put ting it in the wrong to cook.

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152 Monica still struggles with defectiveness W hen she eats s omething she believes she should not she feels guilty. A discussed later. Monica still struggles wit h feelings of incompetence and dependence when it comes to making decisions. She stated: I find that I have a hard time making decisions without her. N ot that I have to de cision. A $3.00 shirt sometimes can be hard and I think this is ridiculous I u y the frickin shirt. Monica indicated that her thoughts of incompetence still carry over into her work now as she wor ls and wonders if she has done the right thing: The problem is I felt horrible for doing it like that. And I ended up talking to one of the therapists about it because I felt so bad I had done that. That was so w what the heck I am doing. it is not what I want with him sometimes. He would never call me suggesting a feeling of emotional deprivation regarding her father. She al so describes her mother as not she is a rooster. Monica also discusses feelings of emotional inhibition in an effort to avoid disapproval b y others and also to hide her own feelings of inadequacy and shame. When

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153 she was attempting to control her feelings she w ould move back into her anorexic behaviors and control her eating. She stated: Sophomore year I dropped back down because I did rush and something terrible, would just have said forget you guys but I dropped back down to 95 pounds. led my weight. Ah control led my emotions. Probably by not eati ng I probably controlled not my school work, but it was just another way it controlled everything. It was one of the things I was disciplined about. But probably more so my emotions were in control. Oh yeah people f much an identity thing for me. unrelenting standards/hypercriticalness, which she tends t o believe she learned from her nt controlling, but not in a freakish but kind of in a she knows best way. She is anal, clean neat, orde about herself : e way I am. The things that piss me off or create anxiety for me I have realized just recently, or frustrate me, actually frustrate her. She related her eating disorder very clearly to her unrel enting standards when she stated : was just stuck on the calories and my thought process that this thing was something I could looking at the calories and being obsessed about it. I wrote down how many ng and a way to could be skinny. Monica stated that she continues to struggle I do the ted that recently she a nd her husband needed to buy a to spend money on crappy

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154 stuff. S he indicated that she is making improv ements even though it continues to be a I want to do the best job and the best job to me is that you have all the information. I have I Monica is the first to admi t that she carried some approval seeking thoughts in During her sorority rush her sophomore year in college she again dropped her weight back down to be noticed and bel ieving it would bring her acceptance: 100 pounds thing for me. hink I am really in control. h and recovery over the years but that there continues to be a struggle with approval seeking. Monica states she has been in constant recovery for approximately 10 years. She relates her commitment to her religion as key to living a recovery life style. While she admits that she still counts points she does consistently appear to address areas that could cause her difficulty. Based on her food journal she appears to eat appropriat e amounts of food to sustain a healthy weight. She admits that even whe n she splurges and eats more sugar than would seem appropriate she does not find a need to punish herself by not eating the next meal or the next day. She indicates because she works in a treatment center she believes she needs to set a good example for h er patients and this helps to keep her honest in her own p ersonal recovery. She indicated that she continues to work on the

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155 areas that cause her difficulty including her perfectionism, and thoughts of dependence/incompetence. Andrea Andrea is a 41 year o ld married Caucasian female. She has no children. She heard about the study from a classmate. Andrea indicated that shortly after graduating from high school she went through about six months where she refused to eat any food whatsoever. When her paren ts became concerned and took her to a doctor he indicated that she was underweight for her height and age and susceptible to having an eating disorder that her body weight was l ess than 85% of what wo uld be expected for her height and age. The doctor recommended that her parents force her to eat and that they track her daily intake. She did not return to the doctor or receive any type of treatment. She associated the start of her eating disorder with her graduation from high school and B eing away from my boyfriend, and being forced to be some I just stopped eating com Eventually her parents a llowed her to return to he r hometown H owever she indicated for a variety of reasons she continued to not eat and not gain goals, I had los four years. And et al., (2003) 18 maladaptive schemas. is abandonment/ instability. She made 11 comments that fi t into th is category. Andrea made a comment regarding a lack of boundaries in her life. When asked by this researcher where that came from she

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156 by her parents when she was eight months old. Her parents were open about her adoption with her and at an early age she felt confident that she was loved and wanted. However, during middle school a friend began teasing her and this made her insecure. She stated: I was in seventh grade and a family friend that went to school with us his parents loved and I was g t had a profound e trying to understand why anybody would want to give you up and not understand ing Andrea stated that she thought about trying to find her birth mother during her adolescents H what to expect. Not knowing how I would react to them or how they would react to me and the fear of being rejected becaus years old she decided that she wanted to attempt to find her birth parent. Her birth mother was found by a mediator through the courts. H owever the mother refused to meet Andrea. The process of locati ng her was long and difficult and when the birth mother be her feeling of abandonment one more time. She stated: So that is where a lot of this whole rejection came int o play. Abandonment and not loved and trying to find my place. That one incident in middle school caused Her concerns regarding abandonment also played a role in her inability to set boundaries around her oldest brother and his calls from prison. Andrea indicated that she was the closest in vicinity to her brother when he went to prison. He would call her

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157 collect to talk at odd hours of the night and she would always take his calls. She stated: there for him Andrea also commented about her thoughts of abandonment regarding her high school boyfriend. He rec eived a scholarship to a school in another state. Andrea stated Andrea admits that abandonment is an area in which she continues to have problems. Her mother has bee n ill lately and at times was too tired w hen Andrea called and would ike she, when I call her up and indicate she knows she is not being rejected but at the same time she struggles to not first consider this as being abandoned by her mother before more realistic thoughts come to mind This is an example of how maladaptive schema from childhood can continue to play a role in behavior and thinking as an adult The one comment Andrea made in the category of emotional deprivation helps to explain her thoughts of rejection. In reference me t Andrea made one maladaptive comment in reference to her adoption which fit into the category of defectiveness and shame. When she was struggling with comments my place in the world and trying to understand why anybody would want to give you up.

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158 Andrea talks about her relationship with her boyfriend in high school in terms of what appears as a much en meshed relationship. She admitted that she was obsessed with their relationship. She stated : him. I would give up anything and everything to make sure that I co uld be with him. I had nothing for myself. Everything was around him. She indicated that even after her parents gave in and let her move back to her home town she continued to not eat. By the time she moved home her boyfriend was leaving for college, leavi had nothing for myself. Everything was around him and everything was around my A moderate area of concern for Andrea is mistrust/abuse. She made several comments th at fell within this maladaptive schema. When talking about her father she he was physically and verbally. He was v her mother and h er brothers out of the house in an abusive rage and keep Andrea inside the hous e with him because he knew the a parents re lationship was that she would not allow herself to be tha t dependent on another person. I refused to live like that, I refused. The biggest impact was that I would go get be able to support myself no matter what and that was the most important thing to me.

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159 However once she started dating her boyfriend in high school she completely forgot her resolve for several years while she gave up her own life in order to constantly be a vailable for him. This behavior played into her eating disorder. Once she figured out what she was doing and re established her own goals she was able to get back on track regarding her ability to be an independent person. She also commented regarding h er mean to me. But then they were very controlling of me. They were pushy, demanding k of trust stating: many people because somewhere along the line they are going to hurt me. They are going to reject me. What my dad did to my mom. What he he will always be that way. Th us her mistrust particularly related to her father and her brothers continues to be a problem for her. Andrea made a number of comments that fit in the category of self sacrifice. She has a tendency to meet the needs of others before considering her own in order to ma intain connected to other people in her life. Her oldest brother spent time in prison for passing bad checks. At the time he was in prison her parents lived about 3,000 miles away and her middle brother was in the military. Andrea believed that she needed to dumped on. I was the person he called at five in the morning every time he was allowed d if she had a problem with boundaries. I sacrificed my education to tr

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160 Andrea also talked about self sacrifice in the process of searching fo r her birth mother. Through the entire process she was constantly concerned about hurting other people in her life. She first indicated that she was uncertain about finding her birth biggest fears is search for her mother was not an easy task and took some unfortunate turns. Her mother was located by a court appointed mediator. When she was located the birth mother was uncertain about whether or not she wanted to meet Andrea. The process was long and eventually disappointing for Andrea as her birth mother eventually decided that she did was very self sacrificing. At first I was very understanding because I was really trying to put myself in her place because that is the only way I am going to get through this without having a heart attack. And I kept thinking how she must feel. What s he might think what about it from her perspective. At some point in the process her birth mother agreed to accept a letter from Andrea but first about her birth mothers f eelings and needs over her own. Andrea also commented about her self sacrificing behaviors in relationship to her fam ily. When her brother was released from prison he immediately got into more trouble with the law and he disappeared for 13 years. During the first several years Andrea again sacrificed her need s for the needs of her family as she stated education to try and be there for my family. I had nothing, I had lost all my goals, I had lost Andrea continues to struggle with

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161 self sacrificing behaviors and setting boundaries. This may play a role in her current admitted binge eating behaviors. Andrea stated standards. She believes that a part of this is associated with her father and his issues with perfection. She recalled that she le abusive punishment they received. As they were punished for a mistake she learned to not make the same mistake. Her unrelenting standards also showed up in her search for her mother. When she was told that her birth mother was willing to receive a letter from And so it took me probably three days to write the letter. And I literally wrote, and wrote, and rewrote and I threw away and it had to be the perfect paper, it had to be the perfect pen, the handwriting had to be perfect. She also commented that her birth mother asked the med and address but then indicated that she would not b e contacting her. Andrea obsessed For the next two years every time the phone rang I became obsessed with who was calling. If I was available I always answered it. I was obsessed with who was calling. If it w me I would go online and research trying to find them. I went as far as to find where they lived, how far that would be from me. Was it possible that it could have been who it was? It was insa ne. It was awful. Every birthday I just knew she was going to call. One of her statements n her comments regarding abusive nature and as her brothers were punished she learned from that. I was always very careful. through. Because I think my dad was abusive to them physically now that I look

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162 back at it as an adult. Because I was scared to do anything wrong. So I tried to be the model child. Her mistrust is also seen in her decision regarding relationships. Because her father was physically abusive to her mother Andrea vowed to never date or be involved with someone who might be like him with anybody like him. I would not date anybody who would drink to excess or ever got intoxicated. Andrea also made two comments associated with approval seeking thoughts. When asked about her pain s taking efforts to write the perfect letter to her birth mother critical in that she really wanted her birth mother to like and accept her. She also commented about her eatin g disorder and the need to seek approval. She indicated that even after being allowed to move back to her home town she continued to avoid eating in She stated: I continued to battle with eating because it was still that he is trying to live his life wanted him to. If I gained weight he would not want me. Andr ea shows good signs of recov ery. H owever it is clear that there are some maladaptive schema that continue to cause concern for her. She is aware of her irrational thinking and recognizes when it gets in the way of her ability to move forward. She continues to ask for support thro ugh therapy when she realizes that she is becoming overwhelmed. She admits that she continues to use food to relieve stress and anxiety W hen she feels like she has eaten too much she will skip a meal or not eat for a day to

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163 make up for the poor eating behaviors She suggests that while she is in recovery she struggles to maintain a healthy weight as food can now tend to be used for comfort, only to punish her self later by skipping meals. Of the 18 categories of maladaptive schema (Young, et al., 2003) the participants in the category of anorexia nervos a made comments that fit into 13 categories. They shared statements in four categories including defectiveness/shame, emotional deprivation, unrelenting standards, and approval seeking. The number of st atements in each of those categories varies from participant to participant. H owever the category that seemed to gather the most statements was unrelenting standards. This may have to do with the strong need to find a way to control something in their l ives. Addressing these maladaptive schema as a standard part of a treatment program may help to reduce the rate of relapse for anorexia nervosa. Comments were made by at least one participant in each of the three categories of disordered eating which r elated to 16 of et al., (2003) 18 categories of maladaptive schema This provides some confirmation to earlier research which suggested the need to consider addressing more than just body, weight and nutrition when treating individuals with anore xia nervosa, bulimia nervosa and compulsive ov ereating resulting in obesity. Summary Chapter F our presents the results of each independent case study. The case studies are group ed by eating disorder which includes four participants in the category of co mpulsive overeating resulting in obesity, three p articipants in the category of bulimia n ervosa, and finally three p articipants in the category of anorexia n ervosa. Each of the

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164 participant s stories is told in her own words with background information and details that are associated with each of the ide ntified maladaptive schema that helped to provide a clear understanding of each participants life events associated with a specific maladaptive schema. In the category of compulsive overeating resulting in obesity fo u r women volunteered as participants to this study. Each told her story in her own words and the et al., (2003) maladaptive schema in common These included defectiveness/shame, mist rust/abuse, emotional inhibition, failure and approval seeking The first participant, Cathy, admitted that she attempts to mask her emotions by eating food. She is aware that she is eating the food in an attempt to make herself feel better and understa nds that when she finishes she feels guilty about her behavior. Joan has strong thoughts regarding her weight and feeling defective regarding her appearance but is not ready to hear how much she really weighs. This is a sign that she is not entirely rea dy to change the behavior necessary to stop being a compulsive overeater and lose weight. Her enmeshment with her mother is a serious concern I t would appear that unless her mother was willing to do something about her own weight issues Joan would not consider changing her own behaviors. Joan admitted that she and her mother are emotional eater s conceding that she tends to compulsively eat when she is bored, unhappy, and feeling stressed. Laura continues to have unresolved issues surrounding the man she has called her father and h is abuse both mental and physical to her. Because o f this relationship and an abusive relationship with a boyfriend years ago she continues to find herself as defective and a failure. She continues to use food in an effort to make herself feel better. The final

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165 participant in this category, Margaret also clearly admits that food is an emotional crutch. She started trying to mask feelings of loneliness, abuse and mistrust from about the age of seven and continues to use food today when she is feeling a need to inhibit her emotions and to mask her frustration when she is nonassertive. Three women volunteered to participate who were in various stages of recovery from bulimia nervosa. Each admitted to purposely binging an d purging for at least two years. Recovery for the three women ranged between two and 15 years where at least no purging activities have occurred. Donna has been in recovery for two years and has not binged or purged She maintains a normal weight She is working a twelve step program for her recovery and appears to have the strongest recovery of the three participants. She still struggles with approval seeking behaviors having never received the approval of her mother. Seeking approval continues to c arry over into her current relationships and a need to be accepted. It was clear to this researcher that Donna is able to apply a 12 step program to her eating disorder and has had some success at working through some of her maladaptive schema particularl y in the area of defectiveness/shame as she has a much f the self critical defectiveness/shame and approv al seeking. She continues to struggle with finding a way to fit in. She admits that she still will occasionally binge on food without purging. She justifies this behavior by suggesting that she binges on cereal whic h she considers a healthy alternative She continues to appear vulnerable to relapse since she has not entirely gotten the binge behavior under control. Carla continues to struggle with self

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166 sacrificing behaviors as well as feeling emotional ly deprived in her close family relationships. Sh e also made strong statements in the categories of mistrust/abuse and unrelenting standards. Her mistrust also relates back to being sexually abuse as a child and feeling abandoned by her mother as a teenager. This makes it difficult for her to trust new people in her life. She no longer binges or purges food, however, her weight is closely bordering on obesity at this time. She denies overeating but admits that in the past that keeping her weight up did help her feel safe and unattractive to men. Whi le her bulimia appears to be under control Carla is unable to maintain a healthy weight which would indicate that she continues to struggle with maladaptive schema. Resolving some of these issues may help her to maintain a healthy life style. Three wome n volunteered to participate in the category of anorexia nervosa. Each participant at some time in their lives maintained a body weight that was less than 85% of what would be expected of a female of the same height and age. All three participants expres sed a fear of gaining weight or being fat and each admitted to not understanding the seriousness of their low weight prior to recovery. All three women indicated a belief that they are currently in recovery from anorexia nervosa H owever each continues to attempt to control weight by counting points, overeating and then restricting, or switching to binging and purging rather than restricting. Despite this behavior two participants maintain their weight at the low end of normal range. The third struggl es with being overweight according to the body mass index. Six maladaptive schema stood out in the conversation with Jillian. While she did not make numerous comments in the areas of defectiveness/shame and incompetence the comments she did make seem to drive her decision making and anxiety related to her eating disorder. She

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167 also made numerous comments in the area of mistrust/abuse, emotional inhibition, insufficient self control and unrelenting standards. These areas still appear to cause her problem s. Until she is able to address many of the issue s related to these categories she is likely to be susceptible to relapse. Monica has successfully remained in recovery for about 10 years H owever she continues to count points related to calories. She has maintained a healthy weight within a normal range for her height and age but tends to be at the low end of the range. She admits that she still struggles with maladaptive schema associated with unrelenting standards, approval seeking and dependence in competence. According to her food journal she does eat reasonable portions of all types of food S he indicated that even when she does splurge on sugar she does not see a need to punish herself. She does, however, work in an eating disorders clinic and therefore admits that she wants to try and set a good example for her patients. She continues to work on her unrelenting standards and issues regarding dependence incompetence. Andre a the third participant, has not restricted for about 20 years. She n ow appears to struggle with overeating when she is attempting to inhibit emotions. She admits that when she does overeat she may skip the next meal or not eat the rest of the day in order to make up for her overeating. She struggles with a lack of bounda ries, a fear of rejection or abandonment, and mistrust/abuse. She is aware of and takes responsibility for her irrational thoughts and asks for support when she needs it. She continues to struggle with the use of food for comfort. Working through some of her maladaptive schema may help to put some of these behaviors to rest.

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168 Young et al., (2003) developed 18 categories of maladaptive schema 16 of which were identified by one or more of the participants This suggests the need to consider addressing mo re than just body shape weight and eating when treating individuals with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity. All ten participants held defectiveness/shame in common. From a treatment perspective it wo uld b e possible to address this maladaptive schema as part of the group process which is commonly use d in the treatment of eating disorders. Bulimia nervosa and anorexia n ervosa participants a ll made comments in the categories of emotional inhibition and unrel enting standards. These two maladaptive schemas could be addressed as part of the standard treatment for the two disorders either in group or individual treatment. Bulimia nervosa and compulsive overeaters resulting in obesity held mistrust/abuse and emo tional inhibition in common which would allow these maladaptive schema to be addre ssed in a mixed group setting. Chapter Four presented the results of the data collected from the participant interviews. Coding of the data resulted in a wide range of inf ormation regarding maladaptive schema associated with three types of disordered eating; anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity. Chapter Five will provide conclusions drawn from the data analysis, propose suggesti ons for future research, and discuss recommendations for use in the field of counseling particularly associated with counseling for eating disorders.

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169 Chapter Five Summary and Conclusions Chapter Four presented the reduction and interpretation of data from 10 qualitative interviews into a useable form at The 10 participants provided extensive information regarding the existence of maladaptive schema associated with three types of disordered eating. Four partic ipants identified as compulsive overeaters resulting in obesity m ade statements which fit into 15 ) maladaptive schema while three participants diagnosed with bulimia nervosa identified with 1 6 et al., maladaptive schema The three participants included in the group with ano rexia nervosa identified with 13 et al., maladaptive schema. Each of the case studies was presented independently from the others with a short discussion regarding the overall findings in each spe cific category of disordered eati ng Chapter Four concluded with a summary of each category of disordered eating and the maladaptive schema identified in that category. Chapter Five presents a summary of the information that directed this study which includes a statement of the problem, the methodology followed for conducting the research, the findings associated with each case study and t he relationship to each of the maladaptive schema identified in each category of disordered eating. It will also present the conclusions derived from these findings followed by the implications these findings may have on the future treatment of disordered eating. Each of the research questions

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170 will be reviewed and answers will be proposed and supported by the findings of the research and the supportiv e literature S uggestions will be presented as to how this research may be used in the counseling profession. Finally, limitations identified in this study will be discussed along with the suggestions for future research. Summary Previous chapters in th is study created the structure and protocols to be followed for this research project. The goal of the study was to identify maladaptive schema associated with disordered eating, specifically related to compulsive overeating resulting in obesity, anorexia ner vosa and bulimia nervosa. The data collected was rich and thick with content and provided excellent material for analysis. This summary of the previous chapters will paraphrase the key elements and finding s of this study and will help to set the stag e for a comprehensive interpretation. Statement of the Problem Treatment models using cognitive behavioral therapy to treat disordered eating have suggested that those diagnosed with an eating disorder tend to judge themselves in terms of their body sha pe weight and eating habits, and lack the ability to control these three specific types of maladaptive schema (Fairburn, et al. 2003). However, the recovery rate for those treated for an eating disorder that only addresses the three issues identified a bove is less than 50% (Argas, 1997). It is also reported that the relapse rate for anorexia nervosa is 35% and the rate of relapse for bulimia nervosa is 36% of those who actually complete treatment (Keele, et. al., 2005). A number of quantitative studi es have provided evidence that other maladap tive schema may contribute to bulimic behaviors (Leung, et al., 2000; Meyer, et al. 2000; Spranger, et al., 2001; Waller, et al.

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171 2002; Waller & Thomas, 2000 & Waller & Watson, 2000). Fewer studies have address ed this issue in relationship to anorexia nervosa or compulsive overeating resulting in obesity H owever the few studies found indicate d similar findings (Waller, 2002; van Hanswijck de Jonge et al., 2003). If 50% of those seeking treatment for disorder ed eating fail to reach the recovery phase using the cognitive behavioral model that address es only eating habits, weight and body shape, and 36% of those individual s who are reported to reach recovery u sing the same model later relapse then identifying and addressing other contributing maladaptive schema may help to increase the rate of long term recovery. Young et al., (2003) indicated that schemas that develop from toxic childhood experiences may be the core of many chronic Axis I disorders. While t here is no DSM VI TR (American Psychiatric Association 2000 ) diagnosis for obesity, anorexia nervosa and bulimia nervosa do fall in the Axis I category and therefore may also be impacted by such toxic childhood experiences as described by Young, et al This study further explored and identified other maladaptive schema associated with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity that may be interfering in the long term recovery pro cess. Methodology This research is a collective case study which use d a natural setting and allowed the participants to express thoughts and emotions that surround ed their disordered eating in their own voices. Young et al., (2003) defined maladaptive schema as self defeating emotional an d cognitive patterns that repeat throughout life and may d evelop in response to distorted life events. Young, et al., identified 18 categories of maladaptive schema including abandonment/instability, defectiveness/shame, dependence/incompetence,

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172 emotional deprivation, enmeshment/undeveloped self, entitlement/grandiosity, insufficient self control/self discipline, mistrust/abuse, subjugation, social isolation/alienation, self sacrifice, emotional inhibition, failure, vulnerability to harm or illness, approv al seeking/recognition seeking, unrelenting standards/hyper criticalness, negativity/pessimism, and punitiveness. This collective case study provides evidence that persons diagnosed with disorder ed eating have carri ed early life events into adulthood and that these events have created maladaptive schema which may be interfering in their recovery process. The ten participants involved in this study were each interviewed three times. The first interview was use d to explain the study, answer questions, prov ide a journal for tracking food, and to have the consent to participate in the study signed by each participant The second and third interviews were audio taped and transcribed verbatim. The 10 participants ranged in age from 24 to 41 years and the y vo luntarily agreed to participate in the study. Each transcript was repeatedly read in an effort to analyze all the data. An auditor was also used to provide a second pair of eyes as well as identification and confirmation of the findings to provide trust worthiness to the study. The data was organized according to the three disordered eating diagnose s which were the focus of this study ; compulsive overeating resulting in obesity, bulimia nervosa, and anorexia nervosa. Findings Since the purpose of this study was to identify maladaptive schema associated with disordered eating related to compulsive overeating resulting in obesity, anorexia nervosa and bulimia nervosa the results are presented and the data is grouped according to each disordered eating c ategory. Within each category of disordered eating there is a

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173 discussion of the maladaptive schema which the participants in that category held in common as well as unique variations based on specific participants. There is also a discussion of the comm onalities across all thr ee types of disordered eating. The total findings in this research are a reflection on the experiences of t en women from a rural area of Florida known as Polk County. The participants were either students attending classes at a re gional campus of a larger university system, or living in on e of the small municipalities located with in the county. Polk County has a total popul ation of a pproximately 583,403 as of 2007 (Quickfacts.gov, 2010) Lakeland is the largest city with a popula tion of approximately 93,428 (Polk County Website, 2009). While these participants stories and experiences may be similar to other populat ions they also could be very different. Further research using a larger and more diverse population would be requi red in order to ad dress issues of generalization for this study. This will be discussed i n more detail in the section regarding further research sugg estions later in this chapter. Lastly, the findings in this study have been analyzed for thematic content a nd independently reviewed by an auditor. The auditor did initially code the data independently from this researcher and arrived at her own conclusions and themes. The auditor is a fellow licensed mental health counselor who has a strong interest in the treatment of eating disorders. The auditor and researcher came to a point of consensus and the themes and their labels based o et al., (2003) maladaptive schema categories. The data presented here is the product of this collaborative effort be twe en the researcher and auditor.

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174 Compulsive Overeating resulting in Obesity Four women ranging in age from 25 to 35 years volunteered to participate and qualified for the criteria of compulsive overeating resulting in obesity. For the purposes of this s tudy, compulsive overeating resulting in obesity is defined as the condition of elevated fat masses in the body which have been caused by the use of food and eating to compensate for emotions rather than actually eating due to physical feelings of hunger. None of the four women reported having a medical condition such as thyroid disease or any other disease that would result in being identified as obese due to a medical condition which would have disqualified them from this study In total t he four women in this category identified with 15 et al., (2003) categories of maladaptive schema. The re were three catego ries none of the women identified with; entitlement self sacrifice, and vulnerability to harm Not all the women identified with all 15 categories. Cathy made comments that fell within 1 2 of the maladaptive categories, while Laura made statements that fit into 1 1 categories Joan made comments that fit into 11 and Margaret identified 10 categories of maladaptive schema All four wome n made statements that fit into the categories of defectiveness /shame mistrust/abuse, emotional inhibition, failure and approval seeking All four women identified defectiveness / shame as an area that still creates problems in the lives According to Yo ung et al., (2003) this category is defined as the feeling that one is defective, bad, unwanted or inferior to others. Each of the four women made statements regarding a belief that in some way they were defective or felt shame regarding a specific incid ent from the past which continues to cause concern and feelings of shame in the present

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175 and insecure ile Cathy simply stated her thoughts about her defectiveness Margaret expressed her feelings of shame while referencing one specific incident where she saw her father physically abuse her mother. Her comment ust standing there with the phone in my hand. I remember that incident with the phone being one of the mos in this category however it was considered significant because of her self described feel ing s of shame While she indicated that she now understands that a child of four or five years of age would not likely react any differently under the circumstances, she still daptiv e schema particularly mistrust. Young et al., (2003) defined mistrust/abuse as the expectation that one will be hurt, abused, humiliated, manipulated or taken advantage of. Each of these women expressed thoughts that fe ll within this category. A s Margaret stated: I have blanket trust issues period. But maybe that is why I am not married B ecause my dad is a pretty charming guy and nice, but how can I make sure I was in? I do very much rese hard for me to really feel safe around other people and trust them to get close with them. To connect with them. s his way. Twisting it toward where it worked out to his ben efit. Margaret and Cathy were sexually molested by a family member which they each admitted plays into their lack of trust. cerns for h er own children. She identified her former husband as a great father and someone her children

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176 e for me. I would question what is happening here. biological father. As she stated: his appeared to lead her to a mistrust of men in general as she stated: a lot of around. And because the only guys I saw around my mom I though t the only reason they were around her was because they wa nted something. I thought they just wanted her for Laura was mentally and physically abused by b oth her father and a boyfriend and alluded to sexual abuse but did not want to discuss it as a part of this interview She commented about her boyfrie nd: He was one of those people that would say things that only your enemy would say like he would call me names. He called me ugly, slut and the whatever. Anything that would come out of his mouth. He called me fat. If I gained a little weigh t he would say things like you are unattractive and this and We were out at a function and he poured a 64oz orange soda on my head. call me a slut and whore and t old me that I was doing this and that A s an adult she still avoids him when he has been drinking. S he continued by stating: When he drinks I stay away from him because he becomes abusive. He is no longer physically abusiv e but he is mentally abusive to whoever is around. When I was pregnant with my daughter he would try to get abusive with me again. Each of these four women made strong statements regarding abuses that took place in childhood that they have now carried i nto their adult life in the form of mistrust.

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177 Each of the women also made comments that fit in the maladaptive schema of emotional inhibition admitting to using food to cover up feelings. As defined by Young et al., (2003) emotional inhibition is a wit hholding of action, feelings or communication for fear of being disapproved by others. Each of the women indicated that in order to withhold feelings or push down feelings they would eat food. Food brightens my day. If I am having a bad day and I find out there is free food on campus I a m like, free food, yes! My day just got better. But that is something that is really important to me and makes me feel better. If I am really upset and eat certain foods I usually feel better. l. I pretended around other when discussing how she felt about having orange soda poured over her head by her boyfriend. When Margaret was asked what food provided her she stated: I feel comforted. Oh food feels good in your stomach and it tastes great and it takes you out of whatever painful thing you were thinking about especially if you have to make or go get or wait for someone to bring it to you. Three of the four women discussed t he use of food to inhibit emotions while Laura made comments on her food journal that would suggest she also used food in an effort to feel A ll four women also made statements regarding a sense of failure. Young et al., (2003) defines this maladaptive schema as believing that one has failed or will fail or is Each of the women expressed thoughts

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178 indicating that they p erc eive themselves or they believe that others perceive them as failures. Cathy who works in a major company and has moved into a position of supervision without meeting the education al requirements believes her success is just luck. She also perceiv es that her parenting ski lls are a failure. wife because you know this and that. You pick apart all the things you do in the whole marriage and you t hink I could have done better. Joan sees her inability to lose weight or stick to an eating plan as failing on her part. She continues to be in denial about how much of a problem she has with eating and does not take clear responsibility for her actions. She stated regarding a calorie counting program she attempt ed to use: I was doing really good and it would say I went over my limit all the time. And I really eaten that much. Like it realistic and a lot of the things I woul stopped using it. Joan struggled in this cas e to see that perhaps the option was to choose things that were in the data base rather than the reverse. It would appear as though Joan was setting h erself up for failure. The final category that all four women comment ed in was approval seeking. This i s defined by Young et al., (2003) as having an extreme emphasis on trying to gain approval or attention from others. It is a need to fit in at the expense of not developing a true sense of self. Each of these women discussed clearly a need to seek appro val from really care about what people think of me. Al

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179 approval seeking behavior to being half Caucasian and half of Middle Eas tern decent. As she stated: I wis h I could marry an Italian or American Indian or some other culture that I or that there is something wrong with me because I am a part o f a cu l ture that nobody likes. /shame, mistrust/abuse, emotional inhi bition, failure and approval seeking indicate a possible common link among women who are admitted compulsive overeaters which has resulted in obesity and continue to struggle with obesity. Several other categories of maladaptive schema were identified in the review of each transcript but were not held in common by all four participants. Three women in th is category were the product of divorced parents and each felt that at least one parent had not been available to them when needed. Their comments fit t he category of abandonment which is described by Young et al., (2003) as perceiving that certain people most important in their lives are either unstable or unreliable for support or connection. This leaves one to feel like significant others are unable to provide emotional support, connection or strength that can be depend ed upon For example Joan stated: When I was young she [mom] was always dating a lot. was that she was pushing me away by not spending time with me. rejected because she was working so hard at trying to keep them happy that I

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180 he dad to wake up with the Young et al., (2003) described emotional deprivation as one expecting to receive a normal degree of emotional support from other people but that this expectation is never t ruly met. This may come from a lack of nurturance, lack of empathy and/or a lack of feeling protected. Three of the four women made comments that appeared to fit in the stated: M y Mom worked full time. She would come home and on Sunday she would sle ep all day and I remember watching TV because that would keep me busy. I remember waking my mom up a lot. Hey mom can I eat the Doritos? And she would say no you can have a bowl of cereal. A nd I would be like please, please can I eat the Doritos? And I remember eating a lot. I would have a little carpet It may have been three or four bowls of cereal over five hours. Laura may have made the most profound statements regarding em otional deprivation in relationship to her f amily dynamics and her confusion regarding who her father is when she stated: he was very abusive both physically and mentally. If he was angry he wanted everyone in the house to be angry. I would try to hide in my room and he would literally come back there and tell me to come out of my room and sit in the front and be around him while he was angry. When I first started gaining weight he said he would pay

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181 All three of the same women also made comment s regarding enmeshment in a relationship. Young et al., ( 2003) described enmeshment as being excessively personal individuation or social development to the fullest extent possible. Joan appeared to have the strongest area o f enmeshment. Many of the comments she made seemed to include not only her thoughts on a subject She made numerous comments using the plural form in response to many questions. For example she n to the point where we kind of like our privacy and we are hrough her and doing those things with her you know appear to stem fr om her relationship with her husband. She state f something happens to one of us, it happens t o both of us. We are not se king that she cannot be happy without the support of her husband. Three women also made statements regarding unrelenting standards /hypercriticalness According to Young et al., (2003) unrelenting standards is the belief that one must strive for very high standards in order to avoid being criticized by others. This usually results in extreme feelings of pressure and hypercriticalness toward self and others. Cathy menti herself for not being able to provide that atmosphere. She commented regarding her ex

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182 eat father. I could not ask for any person better. Sometimes it makes Joan commented about her abuse of exercise indicating an unrelenting standard of what she should do more in order to look the w ay she wanted I got older I started exercising. I would do pushups and sit ups for 30 minutes a night. I Margaret seemed to make the most compelling statements regarding unrelenting standards and hypercriticalness when she stated: I would like to think that I am not a judgmental person but I see somebody come in with French tips I make a snap judgment. And the snap judgment I make on them is not one I want people to make about me. Margaret appears to set her moral and ethical values a little on the high side which causes her to be hypercritical of others. As she states: I know how people are suppose to be and I am very a tuned to that. I like order, priority, I like decency. The fact that it has not always been a value of the people around me is painful because I feel like an outlier. And sometimes I ause I have seen the result of it. Because three of the four participants made comments in the areas of abandonment, emotional deprivation, enmeshment, subjugation, social isolation, and unrelenting standards these categories of maladaptive schema shou ld be considered important to the process of recovery from compulsive overeating resulting in obesity. While in each category one of the four participants did not appear to make a specific comment that fit into one of these categories it is possible that with further investigation or through a group process that some memory would be triggered and reported that was

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183 not realized as part of the taped interview used in this study. This may be a limitation of the study which will be discussed later in this ch apter. Cathy and Laura each made comments t hat fell in the categories of dependence/incompetence and insufficient self control D ependence/ incompetence is defined by Young, et al., (2003) as a belief that one is unable to handle everyday life responsib ilities without a considerable amount of help from others. Cathy commented about her decision making process in divorcing her husband. She apparently made the decision to separate and file d the paperwork with the court b ut then for the next two years sh finally my husband said you need to do something and we finally came to the decision to d around her in ability to take ca Each of these women struggles to find their strengths. They are each successful in their own right, Laura continuing with her education against the odds, and ully climb the corporate ladder. H owever neither perceives that they have completed these tas ks on their own. Cathy suggested it is just luck and ap pear ed to depend on others for a boost while Laura appeared to depend on her husband as well as other family members to make decisions Insufficient s elf control is defined by Young, et al., (2003) as an inability to maintain self control and frustration

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184 I cried e very day, I ate, I ate late, su per late because I went to bed late. Two or three in the morning so I would be eating and that is not a good ti me to eat something without realizing that the real issue was within me. anything to do and you just knick kna ck all day lon g. I mean I would open up the pack and eat it all. I find it hard to just fight off just eating something. a need to use food for emotional comfort Each cannot fight the impulse to use food in this way even though they a re aware that it is contributing to their weight problems. They use the food to avoid pain and sometimes conflict at the expense of their own personal fulfillment which fits C onclusion Regarding Compu lsive Overeaters Resulting In Obesity The results of the current study confirm and contribute information to the body of evidence regarding the effects of maladaptive schema in the category of compulsive overeaters resulting in obesity. Accor ding to Bryne et. al. (2003), compulsive overeaters eat in order to regulate mood, and avoid negative feelings. Bryne, et al., conducted a qualitative study to explore the concept that psychological factors were involved in the in ability for women with a history of o besity to be successful with weight loss and maintenance. It was found that 90% of those in the regainer group reported that they were likely to use food during adverse times to reduce stress and anxiety. The result of that study suggested that issues of obesity were not exclusively due to biological problem s and that psychological factors also play a role. The current study helps to confirm that psychological factors particularly in the form of maladaptive schema contribute to the lack of success for co mpulsive overeaters resulting in obesity to lose and

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185 maintain a weight loss. Based on the results of the interviews conducted as a part of the current study, it is apparent that all four women use d food to avoid negative fee lings, and to control or regula te mood vanHanswijck de Jonge, et al. (2003) conducted a quantitative study using the short form of the Young Maladaptive Schema Questionnaire and found significant results in the categories of defectiveness/shame, social isolation, vulnerability to har m, subjugation, emotional deprivation, abandonment, and unrelenting standards in obese participants who had been sexually abused Using an interviewing process the current study reported evidence in agreement with vanHanswijck de Jong, et al. In the curr ent study two of the participants indicated that they had be en sexually abused while a third alluded to being sexually abused but was unwilling to discuss that as a part of her interview process. Regardless of sexual abuse, a ll f our participants did make comments that fell in the category of defectiveness /shame and three made comments related to abandonment social isolation, subjugation emotional deprivation, and unrelenting standards. It was also found in the current study that all four participants made statements that fit the category of emotional inhibition, failure and approval seeking. At least two made comments regarding dependence/incompetence, insufficient self control and one made a comment in the category of punitiveness The only maladap tive schema s that none of the four participants appeared to identify were feelings of vulnerability to harm and negativity. Each of the participants expressed thoughts and fee lings that were identified in 15 hema. Through the review and coding omments fe ll into 12 categories particularly in four distinct areas:

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186 defectiveness/shame, emotional inhibition, approval seeking and her thoughts associat ed with failure. Cathy attempted to mask her f eelings regarding failure as a mother and wife and her defectiveness issues through her compulsive eating. She is aware that she is eating in an effort to make herself feel better and also realized that in the end it made her feel worse. None the less sh e struggles to stop this behavior which showed how strong her maladaptive schema are particularly in these categories. The fact that she failed to return her food journal suggested that writing down her food intake and identifying the reasons for eating may have been too visual for her an d more than she was willing to identify as a part of her interview process Five areas of maladaptive schema s tood out in the 11 categories in which Joan commented Two areas in particular may strongly influence her ina bil ity to identify problem s or lose and maintain a weight loss in a normal range based on the body mass with her mother clearly presented issues with her personal development. While she did not make comments that fit in the cate gory of dependence/incompetence, it is clear that she continues to depend upon her mother for a major part of her belief system. This enmeshment will continue to inhibit her ability to express her individuality. The other area of major concern is defect iveness/shame. Her thoughts regarding her appearance provide d strong statements which fit in the category of defectiveness and shame. Her ref usal to know how much she weighed at the time of the interview suggest ed that she is not ready to stick to a nutr itional food plan or work on issues that trigger her compulsive eating. Laura made comments in 11 categories of maladaptive schema. Her strongest statements and areas of major concern are in the categories of defectiveness/shame,

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187 emotional inhibition, mis trust/abuse, and social isolation The majority of comments revolve d around her unresolved issues with family. By the end of her recorded interview it became clear that she continues to have strong issues with mistrust and defectiveness/ shame particula rly related to her relationship with her father and the way she was treated by him when she was a child. Margaret made comments in 10 categories of maladaptive schema. Some of at she stil l struggles with her ability to be assertive and express her thoughts and feelings to others. She continues to identify with that compliant child who could sit quietly for hours and wait on her mother to come home. She admitted that she tends to be passive aggressive rather than confronting issues outright, just as she did as an adolescent when she realized she could just turn off the television a half hour before her mother came home. She also continues to have strong emotions regarding mistr ust particularly in her willingness to build new re lationships related to the abuse she witness ed by both her father and mother. Margaret successfully lost weight several years ago when her doctor warned her of some health issues. She has regained all t he weight and the health issues have returned. H owever, her inability to re commit to loosing the weight may be a direct result of the maladaptive schema that continue to play a role in her thought process es Further discussion regarding the importance of these findings and possible use in the treatment of disordered eating will be discuss later in this chapter regarding overall conclusions, possible uses, and limitations of this study.

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188 Bulimia Nervosa Previous research indicates that maladaptive schema m ay predict binging and purging behaviors in those diagnosed with bulimia nervosa. The research suggests that binging and p urging are related to reducing emotions particularly those associated with defectiveness and shame (Waller, et al., 1999). In all, 14 studies found a relationship between maladaptive schema and binge purge activities in participants diagnosed with bulimia nervosa. The current study found that three participants diagnosed with bulimia nervosa were identified as havi ng thoughts an d bel iefs that fa l et al., (2003) maladaptive schema categories. All three participants made statements that were coded in the categories of abandonment, defectiveness/shame, emotional deprivation mistrust/abuse, emotional inhi bition, and unrelenting standards Each of the women made comments that suggest ed a perception on their part they were abandoned by one or both parents at different times in each life. made several comments regarding her relationship with both parents that fell into th e category of abandonment Donna recalled that her fathe r, on more than one occasion rescued and protected her from her mother who appeared to be more volatile in her re lationship with Donna. However when her father sought help for his alcoholism he then became obsessed with orced and then he knew we were regarding abandonment when she was being sent from one parent to the other to live because neither parent seemed to know how to cope with her behavior:

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189 M y mother sent me to live with my father. I was 15 and I stayed there for four the n my mom put me in a teen crisis shelter. Jade recalled feeling abandoned when she was left in Mexico at the age of 17 years old to live on her own. She stated: My parents said we would move back to Mexico after I graduated. Once we were there they decided not to stay and so I was left alone. For those nine months I was pretty much l Jade also expressed feeling abandoned because both her parents worked so hard when she was young that she felt like she had no mother in terms of abandonmen t/instability in three words mother moved to Florida and actually left me with my step dad until I graduated from All three participants expressed concerns that one or both parents were unreliable and were unable to prov ide them the protection they believed they needed. All three participants made comments in the category of defectiveness/shame confirming for each of the participants their feelings of being bad, unwanted or inferior in some aspect of their lives. As D some about how her recovery program has helped her to work on her defective and shameful thoughts and feelings. She stated: I have to practice at being somebody that I want to be and I think it was six m onths ago that I finally started to feel really successful at this practicing being someone that I wanted to be thing and I started to feel a lot of these feelings of e steem.

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190 with growing up both in Mexico and the United States and struggling to figure ou r how she fit in. As she stated : or bein g I got the more my mother pointed out that I was getting too involved in the American life style and that I was denying my roots. Carla made only a couple of comments that fit into this category. In reference to helping to r aise her step daughter she felt that perhaps she was inadequate as a parent and in this regard she stated All three participants also made comments in the area of emotional deprivation. Young et al., (2003) described this maladaptive schema as the desire for a normal degree of emotional support. Each of the three participants made comments that showed their thoughts and feelings regarding a lack of warmth and affection and lack of guidance being offered to them by family. me. She would not m med from her lack suggested she wanted was : emotiona l l y deprived by the adults in her life growing up. As she commented about her mother abandoning her and moving to Florida she also indicated that her stepfather a parent either. He was more like a pe rson who kept the lights on. He

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191 All three participants identified issues in the maladaptive schema of with her mother. As she commented very simply : when asked to describe her mother. She commented further : i ssues with mistrust/abuse also stem from her relationship with her mother. As she indicated : A t the same time that if you get to o Ba sed on the experiences Carla had during childhood she commented : much that it is fairly easy for me to not rely on anybody in any situation. Emotional inhibition is the need to inhibit spontaneous actions in order to avoid disap proval by others (Young, et al., 2003) Donna commented that when her parents were kicking her b inging and purging to inhibit ing st ressed and I would eat, and eat, and eat, and then just get rid of it again. There was a lot Mexico on her own and not knowing how to deal with her emotions particularly of feeling lonely. She stated: know how to cope with it any other way and the coping mechanism came in that and I wi ll stay skinny. While you are eating it just kind of relaxes you. to avoid feeling them by binging and purging only to feel quilt and shame later.

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192 Carla suggested that she and her husband struggle with the ir ability to share cream at night or we will bond over food, popcorn, and a movie instead of actually sex with food she indicated : her emotions with the use of food even though she no longer purges afterward. In all three cases each of the participants appear ed to be inhibiting sadness, frustration, stres s, or even anger with the use of food to find a way to feel better about themselves or their situation. All three participants made strong statements in the category of unre lenting standards. Each appeared to have set very high internalized standards reg arding their behavior or performance to avoid being criticized (Young, et al., 2003). Donna Her unrelenting standards regar ding food generally left her believing tha t she had not been perfect in her daily intake of calories and she would then have to purge. She indicated that she set a limit of 1,350 calories and that her rigid black and white thinking would not allow her to go over that. When asked what she did whe n she went over her l imit she stated very matter of factly Jade admitted to being a perfectionist. As she stated: I have always been an over achiever. I think again I always tried to keep the faith that I was that perfect kid who n ever did anything wrong. And as an adult, I still want to keep the th ing that I never make a mistake Jade is working on this maladaptive schema in her recovery A little voice somewhere in the back of my hea d that is just an o ver achiever and it is like

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193 how her bulimia played a part in her unrelenting standards: Once I started to lose weight it was like an addictive quality that I wanted to lose mor e weight. I went through a stag have to try to throw up. I would just get sick. And that was scary th have con trol of it. Two participants also made comments that fit in the category of approval seeking. As Donna stated regarding her relationship with her mother : than everyone else because everyone else will just give it to me and s he made me beg for : then I will be loved, if I do that I will be okay. If I do this then I will be accepted in t she was being ac cepted even by family ex cept if she was thin. Her comment: There was so much of a desire to be accepted and I felt that by losing a little bit of weight that I would be accepted and then it becomes sort of a like a circle. Because people say you look good, so then you want to continue to do it. And it it of the food right away. J ade and Carla also made comments that fit into the three categories of enmeshment, self sacrifice and failure. Jade commented on her relationship with her mother and a belief that as a child she was responsible for her mother. Enmeshment is defined by Y oung et al., (2003) as excessive emotional i nvolvement and closeness with significant others, usually a parent a t the expense of being able to have a normal social development. Jade indicated that her mother also had an eating disorder and that : lea try

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194 to fix her. s no life of her own. relationship for a lot of years. And I have always, out of a sen se of obligation, like Carla struggl es with boundaries which contributes to her issues o f enmeshment She talked about taking a leave of absence from two jobs and driving all night to another state because her half brother indicated that he was thinking about suicide. She believed that other members of the family who lived closer to him wou ld not reach out to help him and therefore she was the only one who could provide support. This also showed the extent to which Carla self sacrifice s to help others before taking care of herself. Young (2003) defined this category as an excessive focus on voluntarily indicated : fit the category of self sacrifice. In reference to her perceived resp onsibility to care for her mother she stated: My dad was working all the time and so it all came down to me. I was forced to grow up real quick when I was little. I had to protect her [mom]. I had to make her feel good, I had to keep her happy. And for a kid that is kind of hard. Carla and Jade also made comments that fit into the maladaptive schema of failure. Young et al., (2003) defined this category as the belief that one has failed or will inevitably fail. There is often a belief that one is s tupid, untalented and less successful than others. Jade commented again regarding her relationship with her mother and

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195 have made the biggest mistake of my lif She also continues to blame herself for the mistakes her st ep daughter has made in her life thinking : back I have learned some things and I think there were so many things I cou ld have done Only Jade m ade comments that showed a dependence and sense of incompetence with that, and giving in to other what every he category of bulimia nervosa t o express statements that fit in the category of social isolation. This stemmed from her childhood when her family moved from Mexico to the United States. Because h er parents were migrant workers and went where the crops were, not only was she unable to speak the language she also found it difficult to establish friendships. As she stated so eloquently: ve to learn a new a lot, you never have talk to anyone because you Jade continues to struggle with socia l isolation. She indicated while her mother tells her she is too Americanized that even when she tries to embrace her Hispanic culture she continues to not be able to do that well enough to please her family. Carla also made comments in the ca tegory of e ntitlement. Carla has begun to question her self sacrificing but has gone to the opposite extreme to entitlement. Young

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196 et al., (2003) described this as having a sense of special rights and privilege This often includes the insistence that one should be able to do or have whatever one wants regardless of what others might see as reasonable. Carl lives as well as having taken on the responsibility of open. As she stated: The point when I was ready to leave him I said, look I opened your business store. I struggled with two electric bills, two phone bills, I mean I did everything. I mean I managed the store and the household and I raised your daughter. I said I gave you 10 years N ow I am going to school. It is going to be harder for me to go to school if I leave you so like it or not you are going to be stuck with me until I finish school. Donna was the only participant in the bulimia nervosa group to make comments in the categories of insufficient self control, subjugation, and punitiveness. Insufficient self control is defined by Young et al., (2003) as a difficulty in exercising sufficient se lf also an avoidance of pain or discomfort, conflict, confrontation and responsibility for ones actions. When asked what Donna thought she gained from binging an d purging, she for my life, myself, my feelings, everything which easily fit s et al., definition for insufficient self control. Donna also commented did something wrong they would take my life away. They would take the little jar that is me and turn it upside down in an effort to control me and I would work to feel nothing. Young et al., (200 3) explained subjugation as someone usually having the perception

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197 rtant to others. This will lead to outburst of anger, passive aggressive behavior, acting out, and substance abuse. Donna clearly f elt that her wants and needs were of no concern A s her parents continued to try and control her beh avior the more angry she became the more she acted out and eventually turned to drugs alcohol and bulimia in an attempt to suppress her emotions. Whi le Donna appeared to have the best recovery program of the three participants in this category, she still admits to some punitive behaviors in reference to her mother. Punitiveness is defined as the belief that people should be harshly punished for their mistakes (Young, et al., (2003) Donna continues to have a love hate relationship with her mother and made one strong giving me her approval so I rejected her as a punishment and as a way of dealing wi th the Conclusions Relating to Bulimia Nervosa The three participants in the current study expressed thoughts and feelings that et al., (2003) categories of maladaptive schema. The only two categories that were not identified by at least one participant in this group included vulnerability to harm and negativity. Through the review and coding process Donna made comments that fell into 10 categories in six distinct areas: abandonment, defect iveness/shame, insufficient self control, mistrust/abuse, subjugation, and approval seeking. Donna practices a 12 step program in her recovery and takes pride in her two years of being binge and purge free. Of the three women s he appeared to have the st rongest recovery and the best understanding of her disease and the recovery process. For example she made several comments regarding defectiveness and shame that show ed

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198 she is working on not only identifying the problem but correcting it as well. A posit ive sign in this regard included her thoughts : a quirky, you know, traits I still need to work on to be of better service to other Donna appeared to have the best understanding of how her maladapti ve schema have affected her bulimia Two areas stood out in the 12 maladaptive schema categories identified in the struggle d to fit in and this issue continue s to be a concern for her. However a good sign had an eating disorder. Unfortunately she has not admitted this to her father because she fears his response. Her need to continue to hold on to the unrelenting standard of not making mistakes may also play a role in her ability to maintain her recovery. Jade has sought out 12 step recovery programs, but has no t consistently attend and admitted that she has not worked the s pecific steps associated with this type of program. Her admission that she still occasionally will binge on cereal may be related to her unresolved issues in these areas. et al., (2003) maladaptive sche ma. Four categories stood out as continued areas of concern and may play a role in her inability to maintain a normal weight. These include d self sacrifice, emotional deprivation, mistrust/abuse and unrelenting standards. The mistrust/abuse appears to be related to unresolved issue regarding her lack of trust related to her mother. She also admitted

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199 Unfortuna tely when she finally identified this behavior she began to lean toward the opposite extreme a sense of entitlement. In the past, the treatment protocol for bulimia nervosa included cognitive behavioral therapy and focused on body shape, weight and eating (Wilson & Fairburn, 1993). Rates of success using this treatment h ave been reported as relatively high at approximately 40 to 50 percent (Agras, 1997; Anderson & Maloney, 2001) Of those who successfully complete d treatment there was a reported relapse rate of 35% (Keel, et al., 2005). This high rate of relapse may ind icate that the scope of treatment should be expanded to include other issues and concerns beyond the focus of body shape, weight, and eating. Several studies using quantitative methods of research identified the existence of other maladaptive schema in pa rticipants diagnosed with bulimia nervosa (Leung, et al, 2000; Jones, et al., 2005; Joiner, et al., 1997; Waller, 2002; Waller, et al., 1999, 2001, 2002, Dingemans, et al., 2006; Cooper, et al., 2006; Hayaki, 2002; Leung & Price, 2007, Rogers & Petrie, 200 1; Hurley, 2008). The results of the current study provide further con formation to the body of evidence regarding the involvement of maladaptive schema on persons diagnosed with bulimia nervosa. Leung, et al (2000) investigated the role of core beliefs in the treatment of bulimia nervosa. The results of the study indicated that even after treatment participants diagnosed with bulimia continued to have more maladaptive core beliefs particularly in the areas of defectiveness/shame, isolation, and social u ndesirability and that these areas were considered high predictors of failure to stop or reduce vomiting (Leung, et al.). Each of the women in the current study indicate d that they have not vomited in the pas t two years prior to this study. H owever Jade admitted to occasional binge behavior and Carla

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200 struggles to keep her weight within a normal range although she does not perceive herself as a binge or compulsive eater. Each of the se women made statements that suggest they still struggle with issues of defectiveness / shame. Jade continues to have with issues associated with social isolation Jade and Donna both admit to continued approval seeking These findings help to provide findings. Heatherton, et al., (1997) con cluded that bulimic symptoms and perfectionism are highly related particularly in the perception of weight. Heatherton, et al., focused on perfectionism as it relates to body image and the symptoms of bulimia. T he current study also found a relationship between unrelenting standards which includes perfectionism and bulimia nervosa. While some of the unrelenting standards reported by each of the participants in the current study related to body image they made other comments that reached beyond that scop self centered faith that I was the perfect kid who never did anything wrong. And as an adult I still want to keep the perfectionist. I expected too much from him [husband] as far as how I think our These respons es show that perfectionism or unrelenting standards go beyond body shape Expanding t he scope of treatment to include other types of perfectionistic behaviors beyond body shape may help to increase recovery rates and decrease the rate of relapse Walle r, Dickson & Ohanian (2002) found that women who displayed more bulimic attitudes perceived themselves as socially different, deprived of emotional

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201 support and had low self control All three women in the current study made statements that confirm ed the conclusions of Waller, et al., in the area of emotional deprivation and would concur with the suggestion that this should be included as a regular part of all treatment programs. Not to dismiss the other findings, only Jade expressed statements regarding her feelings of being socially isolated or diffe rent and only Donna made statements that would suggest insufficient self control. In the opinion of this researcher, binging and purging behaviors are a sign of insufficient self control Thus, since the th ree participants in this study at least denied purging behavior for at least two years this may be why fe wer comments were made in reference to issues of insufficient self control. Overall, the importance of insufficient self control should be recognized and addressed in the course of treatment Hayaki, et al., (2002) looked at the association of shame related specifically to bulimia nervosa and found that women diagnosed with bulimia nervosa d o show higher levels of shame than a control group of non bu limic women. As a quantitative study Hayaki, et al., did not explore particular reason s ex cept to identify a higher rate of depressed mode associated with shame. The current study found that all three women expressed statements associated with defectiven ess and shame particularly in relationship to thei r binging/purge behaviors. H owever, they also expressed statements that appear ed pe for me. There is no reason to try and help inadequate and I still wake up some days and think you have done nothing with your onship with her husband that when he is not

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202 interested in her sexually s he feels unattractive. Depression was not a topic of discussion in the current study, however, each of the statements made by these women expressed a sense of sadness which may or may not be related to depression. While depression may be a concern, at the least issues of sadness should be included and addressed in the course of treatment and depression may need to be ruled out The current study confirm s previous studies indicating t hat maladaptive schema beyond body shape, weight and eating play a role in bulimia nervosa and should be addressed as a part of a standard treatment program for this type of disordered eating An overall discussion regarding the importance of these findi ngs and the possible uses in treatment is discussed later in this chapter. Anorexia Nervosa Three women volunteered to participate in this study who met the criteria for a diagnosis of anorexia nervosa. Limited research has been conducted specific to ano rexia nervosa and the association of maladaptive schema It was found that in much of the literature anorexia nervosa binge/purge subtype was included in studies with participants diagnosed with bulimia nervosa. No research was found that specifically ad dressed maladaptive schema in relationship to anorexia nervosa regardless of subtype. For the purposes of this study anorexia nervosa was included as a separate eating disorder and data was collected from three participants all meeting the DSM IV TR (Amer ican Psychiatric Association 2000 ) diagnosis for anorexia nervosa, regardless of subtype. In et al., (2003) maladaptive schema categories were identified. Of those 13 categories all thre e

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203 participants made comments in the categories of defectiveness/shame, emotional deprivation, unrelenting standards, and approval seeking. All three participants made statements that fit into the category of defectiveness/shame. Jillian may have made t he strongest statement regarding her Monica made statements associated with her relationship with her mother and her feelings of defective thoughts regarding defectiveness come from being adopted and not always clearly understanding her place in her family system. She stated: want to give me up. Then I started to Each of the three participants also commented on emotional deprivation which is generally associated with each participant s parents. Jillian described her father as her father : : stand up to her. Because she i commented about both her parents indicating :

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204 Each of the three participants made numerous statements regarding their unrelenting standard s and need for per fection. Jillian plainly stated : and very contr on her unrelenting standards by sa trying to write a letter to her birth mother she stated: So I had to in my mind create the perfect letter. And so it took me probably three days to write the letter. And I literally wrote, and wrote, and re wrote and I threw away and it had to be the perfect paper, it had to be the perfect pen, the handwriting had to be perfect. The final category in which all t hree participants made comments in was the maladaptive schema of approval seeking Each admitted that some of their unrelenting standards had be accepted. I went to a small school and I had trouble with relationships and stuff, not Monica related her relapse in college to approval seeking. She stated: I slipped back into counting calories and I ke pt it under 100. And I remember people making com if I just had your discipline w as pretty much an think I am really in control. Andrea talked about her need to seek approval from her birth mother. Her lette r to her commented that even though she was allowed to move back to her home town she continued to battle with her eating disorder S he believed her boyfriend was not accep ting her in the way she thought she need ed of me the way

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205 While the three participants all identified four categories of maladaptive schema, at least two of them made statements in five categories. Jillian and Monica made comments that fit in the categories of dependence in competence, mistrust/abuse, and emotional inhibition. For the two women who talked about their thoughts on dependence incompetence thi s continues to be an area of concern for each of them. Jillian stated: fear d this fear to her relationship with her father. As she stated: M ed my decision making. It affec ts how I feel about wishes, allow my partner to make all the important decisions. Monica indicated: I find that I have a hard time making decisions without not that I have to consult her but I have to consult somebody. A $3.00 shirt can sometimes be hard and I think this is ridiculous I should have to call my mom to buy a frickin shirt. Both Monica and Jillian mad e comments that fit into the category of emotional inhibit ion. regarding emotional inhibition clearly show ed hat were coming on so I began relying more on food to feel better. Monica talked about her relapse in college her sophomore year. She indicated that she rushed a sorority and while she was accepted her best friend was not. if I had been th e person that I am today I would have just said forget you guys but instead I d ropped back down to 95 [pounds] indicating her need for acceptance at that time. Over the course of her

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206 recovery Monica believes she has become a different person and would n ot allow herself to give into peer pressure any longer. Jillian and Andrea made comments that fit into the categories of enmeshment, mistrust/abuse, and self sacrifice. While Monica portra yed her mother as somewhat of a mentally abusive person, her discu ssions regarding her mother appeared to fit more closely in other maladaptive schema categories, and therefore, were not included in the area of mistrust/abuse. Both Jillian and Andrea appear ed to have issues of enmeshment with one or more family members. simply takes on the likes and dislikes of the person she is with rather than identifying her own likes and dislikes. This most likely stems from her relationship with her father who continued to make all her decisions up until the time she moved in with her boyfriend. Now she defers to her boyfriend as the decision maker. Jillian also commented that she has Andrea commented on her relationship with her boyfriend: I was that girlfriend that I had to be with him 24/7. My world revolved around him. I would give up anyth ing and everything to make sure that I could be with was around my parents. A t the same time it sh ows her inability to individuate herself from her family. Both Jillian and Andrea commented on issues of mistrust/abuse making statements that suggest a fear of being hurt, humiliated, cheated on or lied to by others. er. She described him as mentally and emotionally

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207 abusing her to a point now that she no longer lives at home and she protects herself protected settings that I can co where she will spend time with him. She indicated that her favorite time is going grocery shopping with him because he will be concentrating on his shopping and coupons and will not have time to foc us on her. Andrea grew up with an alcoholic, abusive father. She indicated that he was verbally and emotionally abusive to her. In her mind she decided that she would never allow this type of behavior to happen in her relationships. She stated: So I refused to live like that, I refused. The biggest impact was that I would go an d me. I would be able to support myself no matter what and that was the most important thing to me. A ndrea and Jillian also made comments that fit in the area of self sacrifice. Jillian only made one comment but it seemed to describe her quite clearly and therefore was gain ties in with her adoptive status and a n eed to find her place within her family. She made numerous comments regarding how she has sacrificed her needs for the needs of her crificed abusive household, yet at the same time her need to be a caregiver pulled her right back in.

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208 Andrea was the only participant in this category that made commen ts regarding abandonment. This again centered around her being adopted. This seem ed to hit home for her in the seventh grade. As she stated: A family friend that went to school with us, his parents were friends with my parents, made jokes about me being effect on me that I understand why anybody would want to give me up and not unde that is where a lot of this whole rejection came into play. Abandonment and not love d and trying to find my place although I always had a place. That one incident in middle school caused me to it had a profound effect on me, that kid te Jillian was the only participant in this category to make statements regarding insufficient self control. She continues to battle with binging and purging She has not been able to make a full recovery f rom her anorexia. She indicated the need to binge and purge overwhelms her and that she lacks the self control to work her way through the thoughts and feelings without acting on them. As she stated: days I am good about it where I will follow my little routine, whatever. And some days starts and it is right there and there is no stopping me. Jillian also commented on her social isolation. She commented that this actually began with her parents whom she de scribed stuff. I st Lastly, Jillian is the only participant in this group to make comments regarding a sense of failure. When asked early in the interview to describe herself she stated:

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209 comment she made in the category it stands out indicating she is being extremely harsh on herself. Conclusions Regarding Anorexia Nervosa et al., (2003) m aladaptive schema Jil l i an identified with 12 categories of maladaptive schema H er strongest statements appeared to fall in the areas of insufficient self control, mistrust/abuse, emotional inhibition, and unrelenting standards. While she did not make many statements in the area of defectiveness and shame and dependence incompetence, the statements she did make continue to be areas of concern and hold the key to her continued relapse. Her statement associated with her thoughts regarding her perception suggests that she still sees herself as defective. She also made an interesting statement regarding her decision making skills indicating she still considers herse lf as dependent through with it I am always asking is this okay, should I do this. I am not really sure of rnal that Jillian returned she continues to restrict calories and appears to eat the very minimum on a daily basis to sustain her energy not necessarily her weight She also admitted that she continues to struggle with urges to binge and purge. While s he does not always g ive in to those urges she admitted that it is a struggle on a near daily basis. Monica showed the best recovery indicating that she has been in recovery for 10 years. She admit ted that she still counts poin ts when planning her food me nus S he does appear to eat appropria te amounts of food and indicated she does not punish herself for a

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210 splurge in food intake. She continues to maintain a healthy weight based on her size. She did recognize that her issues with perfectionism and depend ence/incompetence are still problem areas for her. S he indicated that neither of these areas triggers her need to rest rict in order to find control. Andrea made statement s that were coded into eight et al., (2003) maladaptive schema. She doe s show good signs of recovery for her anorexia H owever it appeared clear that there are a couple of maladaptive schema that continue s to cause concern. Her issues of abandonment stemmed from comments made by a childhood friend related to her being adop ted and carried over in adulthood to being rejected by the birth mother This maladaptive thinking appears to creep into current issues like her adoptive mother everyday and check on her A t certain times her mother did not feel up to talking on the phone. realize that her mother just did not want to talk at that time, unrelated to her feelings about Andrea. Andrea admits that food continues to be a source of control and comfort for her when she becomes overwhelmed. She admitted that she will use food to inhibit emotions W hen she realizes she has overeaten she will at least consider restricting fo r a day in order to make up for the extra calories. While she appear ed to have the anorexia nervosa under control, she does struggle to maintain a healthy weight since food has now become a source of comfort. Only one previous study was found specificall y related to the eating disorder of anorexia nervosa relevant to maladaptive schema Rogers & Petrie (1996) examined the relationship of obssessiveness, dependency, hostility toward self, and assertiveness as it

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211 relates to attitudes and behaviors associa ted with anorexia nervosa. The results of this study indicated that there did not appear to be a direct relationship between the symptoms of anore xia and self directed hostility or assertiveness H owever there was some relationship between symptoms of a norexia and obssessiveness and dependency. Rogers & Petrie did not use participants that were diagnosed with anorexia nervosa I nstead this was a quantitative study where participants were selected who de monstrate attitudes related to anorexia nervosa ba sed on the Eating Attitudes Test developed by Garner & Garfinkle (1997, as cited in Rogers & Petrie). One of the limitations of the Rogers & Petrie study is that none of the women involved in the study were diagnosed with any type of eating disorder T he EAT only reports that there is a propensity for the test taker to have or develop an eating disorder. The current qualitative study expanded on Rogers three participants who fit the DSM IV TR (American Psychiatric Association, 2 000) diagnosis for anorexia nervosa It f ound that all three participants made statements that were identified and coded in the areas of defectiven ess/ shame, emotional deprivation, unrelenting standards and approval seeking. The current study suggests that further research should be conducted regarding the relationship of maladaptive schema beyond body shape, weight, and eating that may be associated with anorexia nervosa. Further discussion regarding the importance of these findings and possible uses will be discussed later in the chapter. General Conclusions Overall the findings generated from the data analysis support ed the goals of the research. A summary of the findings which developed during the process of analyzing the data were presented ea rlier in this chapter The findings are presented in summary

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212 with some interpretation of the result s. The next section provides a generalized discussion of the effect of maladaptive schema associated with disorder ed eating and provides conclusions derive d from these results. Each of the original research questions will be addressed through a synthesis of the data from all three disorder ed eating types that were the subject of this research. Five previous studies used a more generalize approach to ident ifying maladaptive schema related to disordered eating and will be discussed as a part of this general conclusion. A study by Jones, et al., (2005) found that women reporting to be in recovery from a non specified eating disorder score d lower on the Young Maladaptive Schema inventory in the areas of mistrust/abuse, social isolation, defectiveness/shame, failure to achieve and vulnerability to harm than women with a current eating disorder The scores for this recovery group were still higher than scores from a control group of participants who denied every having an eating disorder. All six participants in this study who fit the DSM IV TR (American Psychiatric Association, 2000) diagnosis of either Bulimia Nervosa or Anorexia Nervosa indicated that they saw themselves as being in recovery. H owever all six participants made statements that would suggest that they may still be struggling with issues associated with defectiveness/shame while five indica ted concerns with mistrust abuse. Fewer indicated is sues with failure, and social isolation. The current study found that all the participants in the categories of bulimia nervosa and anorexia nervosa made statements that fit in the category of emotional deprivation and unrelenting standards. Issues with emotional deprivation appeared to be associated with unresolved issues regarding relationships with one or both parents. Each participant made statements that suggest that they still ma y not have the relationship they desire. For

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213 example, Monica stated: A study by Leung & Price (2007) found that a group of participants with an unspecified eating disorder scored significantly higher o n the Young Schema Questionnaire Short version in the areas of emotional deprivation, mistrust/abuse, social isolation, defectiveness/shame, failure to achieve, dependence/ incompetence and vulnerability to harm. The current study agree s with the majorit y of findings in the Leung & Price study. Seven of the eight categories were also identified by one or more groups of participants in this qualitative analysis. Interestingly, two cat egories did not appear as area s of concern for any of the participants in the current study : vulnerability to harm and negativity It should be noted that v ulne rability to harm presented a source of some debate for this rese archer and the auditor. Young, et al., (2003) defined vulnerability to harm as an that im minent ). Throughout the review several of the participants made comments that at first glance su ggested a vulnerability to harm. B ased on Yo ung definition none of the statements appeared to identify a n ex aggerated fear that imminent catastrophe would occur to self or others, therefore those statements were reviewed and found to fit better in other categories such as continued et al., strong definition made it difficult to identify this category in this qualitative study. However the Young Schema Questionnaire identified specific

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214 statements which participant s a re asked to rate. Those statements could provide a more clear and specific pictu re of vulnerability to harm which could explai n the differences in the results between the current study and that of Jones, et al., (2005) and Leung and Price (2007 ). Another maladaptive schema not found in the coding process was n egativity Th is maladaptive schema is defined by Young, et al (2003) as a pervasive, lifelong focus on the negative aspects of life which u sually includ es an exaggerated expectation that things will ultimately fall apart. While all 10 women discussed the negative aspects of previous life events none of them indicated they believed they had no hope of a better future and therefore their comments fit better in other categories of maladaptive schema. Each has been successful in her own right at work, and in her personal life; and all identify some personal strengths which co ntinue to motivate them forward. This may help to better understand why neither the researcher nor the auditor identified negativity as a maladaptive schema in any of the transcripts. It should be noted that none of the participants in the category of com pulsive overeaters resulting in obesity were in recovery at the time of this study. Three of the four participants continue to weigh in the obese range They do not show signs of changing behaviors in order to lose weight. The fourth participant was cur rently in the overweight range but was struggling to stay on track toward recovery. Because they are not clearly in recovery this group was omitted from this part of the discussion and relationships made between the current study and the Jones, et al., ( 2005) study. Waller, et al., (1999) questioned whether or not different eating disorders show ed different patterns of core beliefs relative to each other and to a comparison group. The

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215 study included women diagnosed with bulimia nervosa anore xia nervosa binge/purge subtype, and binge eaters, as well as a gr oup of non clinical women The findings indicated that defectiveness/shame was a significant predictor of purging in bu limic women while emotional inhi bition was a significant predictor of binging be havior. Across the board, all 10 participants in the current study made statements coded in the maladaptive schema category of defectiveness/shame A few examples include Joan comment: peless and I feel that I am not good at it. have not achieved what it was I set out t o achieve. Jade also spoke in the present tense Waller, et al (1999) also found that emotional inhibition was a clear predictor of binge eating. The current study confirms this finding as a predictor of binge behavior in all three participants in the category of bulimia. Emotional inhibition appeared to also trigger binge eating in the compuls ive overeaters as well. All seven of the participants in the categories of compulsive overeating resulting in obesity and bulimia nervosa made statements that related to attempting to inhibit emotions through the use of large times I ten Cathy related this to a ust shoveling piles in my mouth and all of the sudden I looked down and realized oh my gosh almost the whole bag was go

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216 Like this eating is going to make me feel better, and it was just a coping mechanism because I was so stressed out that I would eat and then just keep eating and eating and eating and by the time you realize it y ou have eaten so much and then you do not feel good. T he current study shows some agreement with the findings of Waller, et al., (1999) and confirm s that maladaptive schema bey ond the scope of body image, weight and eating should be consider ed for inclu sion in the treatment of disordered eating Dingeman, et al., (2006) conducted a study which included various eating disorders. This study included anorexia nervosa separating the two subtypes of restricting and binge/purging as well as bulimia nervosa a binge eating group and a control group of non clinical participants. All the participants were asked to take the Young Sch ema Questionnaire Short version as well as other qualifying types of questionnaires. Those participants in the study who utili zed purging behaviors were more likely to have maladaptive core beliefs This suggests that purging may not be used just to control weight but is also related to other types of maladaptive schema. The current study also found a relationship between bing ing and purging E ach behavior appeared to provide a source of relief and or comfort. As related above, the compulsive overeaters, as well as the bulimics attempted to emotionally inhibit with binge type behaviors. Jillian was the only identified anorex ic, binge/purge subtype in the current study Her comments confirmed that binging and purging was not entirely associated be want to deal with the emotions that were coming on so I began relying more on food to

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217 Contributions of This Study This study adds to the body of literature and confirm s that maladaptive schema beyond body shape, weight and eating do have an effect on the ability of women diagnose d with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity to recover The participants were very generous with their time and willingness to be open a nd share traumatic events from their lives as well as strong emotional th oughts and feelings Their candidness produced ample data for review. The data is focused on 18 categories of maladaptive schema (Young, et al., 2003) and how traumatic events in the lives of these 10 partic catego ries as seen in Table 2 Table 2 Relationship of maladaptive schema to each of the disordered eating categories Disorder/ Maladaptive Schema OE OE OE OE BN BN BN AN AN AN Abandonment X X X X X X X Defectiveness X X X X X X X X X X Depe ndence X X X X X Emotional Deprivation X X X X X X X X X Enmeshment X X X X X X X Entitlement X Insufficient/ Self Control X X X X X X Mistrust/ Abuse X X X X X X X X X Subjugation X X X X Social Isolation X X X X X X Self Sacrifice X X X X X Emotional Inhibition X X X X X X X X X Failure X X X X X X X Unrelenting X X X X X X X X X

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218 Standards Vulnerability to Harm X X X X X X X X X Approval Seeking X X X X X X X X X Negativity Punitivenes s X X Table 2 shows the relationship of maladaptive schema to each of the disordered eating categories. Compulsive Overeaters resulting in Obesity are represented by the xia Nervosa were made by a participant in the study specific to that category of maladaptive schema. The shading represents the relationship of maladaptive schema asso ciated with each type of disordered eating. It also shows which maladaptive schema within and across the three types of disordered eating were held in common. A second contribution is that it helps to identify maladaptive schema using a conversational in terview process which might be similar to a ny psycho social assessment used in treatment. It is the opinion of this research er that many people who seek treatment for disordered eating focus on body shape and weight as key issue s when they enter treatment This may explain the focus of cognitive behavioral treatment in the past. Howev er with a relapse rate of approximately 35% of those who complete treatment it becomes clear that other issues play a role. One assumption guiding this study was maladapt ive schema contribute to the inability of those diagnosed with disordered eating to sustain a long term recovery. Several previous quantitative s tudies provided a variety of conclusions regarding the various maladaptive schema s involved in disordered eati ng The studies agreed that more maladaptive sc hema should be addressed in the course of

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219 treatment in order to gain long term recovery The purpose of the current study was to use a qualitative approach in order to further explore and identify maladaptiv e schema associated with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity that may interfere with long term recovery. A n interview process similar to assessing a potential client for treatment was used rather than asking p articipants to fill out numerous types of t esting materials Through the course of conversation 10 participants in this collective case study reveal ed a variety of maladaptive schema which appear ed to be associated with their ability to be successful in long term recovery Table 2 provide s a breakd own by disordered eating category and maladaptive schema categories all of which have been discussed earlier in this body of work It was anticipated by this researcher that these three disordered eating catego ries would share more maladaptive schemas in common T he more categories of maladaptive schema that were held in common the more that could be used in a common group setting that addressed any type of disordered eating during treatment Unfortunately, wi thin the group of 10 participants in this collective case study only defectiveness/shame appeared as a common thread to all th ree types of disordered eating It is important to point out the strength of this specific maladaptive schema While some of the defectiveness/shame was related to body shape it is clear that the statements made by the participants regarding defectiveness/shame go beyond that scope. For example ability to be a good mother, a go od employee, and a good wife and clearly described her thoughts of being defective. This shows that defectiveness/shame, as a maladaptive schema clearly needs to be a part of any group th erapy program that addresses disordered

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220 eating. Th e fact that no other maladaptive schema appeared to transcend all categories of disordered eating may be simply a limitation of how this study was conducted. Further research is necessary to resolve this concern. Recommendations for Use The f indings of t his study provide some possible recommendations f or the use of maladaptive schema in the treatment for disordered eating. It is very i mportant for counseling profession als to stay current with trends and realities in counseling This can be done through continued research and clinical observations. T he findings in this collective case study confirm a trend identified in earlier research that maladaptive schema beyond body shape, weight, and eating play a key role in the recovery and relapse of person s di agnosed with var ious types of disordered eating. It also offers the counseling profession suggestions in three areas of case conceptualization, intervention planning, and training to provide better outcomes in the treatment of all types of disordered eati ng. Case Conceptualization Case conceptual iz ation provides the counselor with an empathetic understanding allowing counselor s to identify the influences and interactions that may be a ffecting the client. Understanding and identifying maladaptive schema beyond body shape, weight, and eating have an effect on disordered eating is critical to helping the client to reach and stay in recovery The current study confirmed previous studies that maladaptive schema beyond body shape, weight and e ating should be included to achieve a successful outcome in the treatment of disordered eating adding to the body of evidence and

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221 creating a more complete understanding of the problem at hand. Comp rehension of the number and identification of all possible maladaptive schema involved in disordered eating will all ow for the development of more a ffective interventions by counselors who chose to treat disorder eating. Planning Interventions The partici pants of this study have provided evidence related to 16 defined maladaptive schema which may be involved in the lack of recovery and/or relapse process of disorder eating. These findings provide information that can promote the development of more effect ive interventions for working with clients diagnosed with disordered eating Through effective conceptualization regarding how maladaptive schema are involved and affect the process of recovery a nd relapse in disordered eating, interventions can be planne recovery This can Training Implications Knowledge and understanding of the issues involved in disorder eating i s crucial t o providing effective treatment. In order to consider treating eating disorders counselors should consider this an area of specialization and seek out training prior to offering treatment to a client diagnosed with disorder eating The majority of studie s found in th e review of the literature indicate d that the concept of more maladaptive schema being involved in disordered eating beyond body shape, weight and eating has only been seriously investigated over the course of the last 10 years. Development of treatment protocols addressing a variety of maladaptive schema may be limited and still in the

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222 development process. Further studies may be indicated in order to truly understand the impact on the treatment process. Recommendations for Additional Resea rch The current study helped to confirm previous research that maladaptive schema beyond body shape, weight and eating are involved in disordered eating Wh ile other studies have included binge eating disorder, the current study cho se to expand the conce pt of binge eati ng to compulsive overeating resulting in obesity. This researcher elected to pursue this direction due to the fact that obesity is a major issue particularly in the United States ( Cooper & Fairburn, 2001 ; Flegal, et all 1998). Binge e ati ng is described as a specific disorder in the DSM IV TR (American Psy chiatric Association, 2000 ) H owever, compulsive overeating and obesity are not listed as disorders. It is the opinion of this researcher that there are some similarities and difference s in binge eating and compulsive overeating. Binge eating disorder requires that binge episodes occur at least 2 times a week ( American Psychiatric Association, 2000). While it could be considered that compulsive overeating is a form of binge eating, bin ge eaters do not necessarily fall in the categ ory of obese. A person with a binge e ating d isorder may only binge under extreme periods of stress, anxiety or depression. C ompulsive overeaters tend to binge more often and for more reasons as the current s tudy identified 16 of et al (2003) maladaptive schema This culminates in extreme weight gain and over time can result in obesity. Since this is one researcher s speculation this should be an important topic for future research that could comp are maladaptive schema involved in b inge eating and compulsive overeating resulting in obesity.

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223 The majority of research to date regarding maladaptive schema associated with various disordered eating generally combi ned or included more than one type of dis ordered eating as a topic of the research. Future quantitative studies might consider identifying maladaptive schema associated with a particular type of disordered eating rather than contrasting and comparing the effects of maladaptive schema on two or more types. More studies that are specific to one disorder or another could help in the process of identifying the specific maladaptive schema that can be included and consistentl y used in a treatment protocol. While contrast s and comparison s are importa nt and move the investigation forward it does not necessarily help in the identificati on of protocols for treatment. One of the issues identified in the research was the high rate of relapse in those who successfully complete d treatment for disordered eat ing With the contribution of the new research which has identified other maladaptive schema involved in disorder eating it seems prudent that a longitudinal study would be another course of research. A longitudinal study could include the development o f a treatment protocol that addresses other maladaptive schema associate with eating disorders beyond body shape, weight and eating. After setting and using the protocol in treatment the study c ould follow the progress in the continuing recovery of the p articipants referred to the study for treatment to determine if the treatment of more maladaptive schema in fact decrease s the risk of relapse in clients who successfully complete treatment The study could check on the progress of the participants at two and five years post treatment f or an update on their recovery.

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224 Young et al., (2003) indicated that t he Young Sc h ema Questionnaire can diagnose maladaptive schema in a number of Axis I disorders. It would appear from the research that this does include e at ing disorders that are listed as Axis I in th e D SM IV TR (American Psychiatric Association, 2000 ) However the d evelop ment of an assessment tool specific to disorder ed eating may help to identify issues that are specific to the s e disorder s Further re search is necessary to better understand which categories are more likely to be associated generally with disorder ed eating. Having a diagnostic tool specific to disordered eating could help in the process of treatment planning and the organization of gro up and individual therapy. Limitations This study was intended to further the understanding of the effect of maladaptive schema on disordered eating. As a qualitative study, the results were not intended to generalize to the total population of those diag nosed with disorder ed eating. The experience of the 10 participants in this study suggests a trend supporting the concept of transferability to a larger population of persons diagnosed with disorder ed eating H owever there are a few limitations to the sa mple and the research design that should be addressed in order to assess the strength of the findings. First, there were only 10 participants in total and three specific types of disorder ed eating were being explored. Four participants volunteered in the category of compulsive overeating resulting in obesity Th ree volunteer ed in the category of anorexia and three in the category of bulimia. While the 10 participants generated an enormous amount of data it should in no way be considered as a representat ive sample of all persons who are diagnosed with disordered eating. Commonalities among the participants in each

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225 category and across categories suggest a degree of transferability. Analyzing data from a larger sample in each category of disorder ed eating would be more labor intensive but could end up producing similar results This would increase the possibility of transferability. Second, a nother possible limitation is the homogeneity of the participants to the population. All the participants involve d in this study live in rural Polk County, Florida. All but two of the participants were students at a regional campus of a major university located in Polk County, Florida. Also in the categories of bulimia nervosa and anorexia nervosa each of the part icipants indicated that they had been and continued to be in recovery for their eating disorder. The results may have been different if the focus included participants who were not in the recovery process of their disorder. This may explain why the parti cipants in the category of compulsive overeating resulting in obesity identified with more maladaptive schema th an those participants in the categories of bulimia a nd anorexia. T he participants in the category of compulsive overeater s resulting in obesity based on current weight suggests that clearly they are not in recovery and therefore continue to struggle with their ability to lose and maintain a health y weight. It was interesting to this researcher that in some case s two out of three or three out o f four participants would make statements that identified a specific maladaptive schema but one participant did not. Because this study used case studies and followed the flow of the conversation it is possible that the participant who did not identify wi th the specific maladaptive schema was simply not focused in that area during that specific interview. T wo possible options could resolve this problem. First, this study only intended to record one interview for the body of the information and one interv iew to add or change

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226 information after review of the transcript. Only two participants actually added information at a second interview. The use of more clarifying questions might have enhanced the process and prompted more information from the participa nt. Second, this study used individual interviews only to gather information. A second interview involving all 10 participants in a focus group might have helped to trigger similar experience s among the participants This c ould have resulted in more com parisons and similarities across the categories of disordered eating. A third limitation was that n ot all the participants filled out and returned the food journals O f those that were returned, several only tracked their eating sporadically. The journa l may not be a necessary part of identifying maladaptive schema however those that were returned did provide confirmation of eating to inhibit emotions as well as other maladaptive schema In the completion of the study it is uncl ear to this researcher that the r e was any real impact on the use of a food journal in the process. It is a lso important to note that one participant indicated she did not want to review her transcript when it was provided to her. She indicated she did not realize how difficult it was transcribed. She gave permission for its use as is. This may not have any effect on the outcome of the data H owever it did not allow this researcher the opportun ity to gather any further information. Since only two participants actually added more information at a second interview once they had read the ir transcripts there would appear to be a strong likelihood that the result s of this specific transcript would n ot have changed the outcome of the study. However, it is important to identify it as a possible limitation.

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227 The number of identified maladaptive schema may also be related to the stage of recovery reported by the participants. For example, Jillian made statements coded into 12 categories of maladaptive schema while Monica only made statements in six categories a nd Andrea made comments in eight Of those three participants, Jillian continues to be the one who continue s to struggle with her recovery. Alth ough she perceives herself as being in recovery, she admitted t hat while she does not restrict her intake as much, she stru ggles with binging and purging. Another possible limitation of this study is that all the participant s self selected to participate in the research after hearing about the project described in a class, or by a therapist, or a friend. It can therefore be assumed that they were seeking to explore these issues and had a level of self awareness that gave them the confidence to consent to be interviewed. The issues of the participants who volunteered may be very different from those who did not choose to participate and even more different than someone who is in a lesser stage of recovery. Future research is needed where recruit ed partici pants appear more reserved at first or who have not had some level of success in treatment to determine if their experiences are different th an those who readily volunteer Researcher bias was a major concern and had the most potential for impacting the r esults of this study. This researcher was responsible for setting up the design of the study, recruiting the participants, conducting all the in terviews, personally transcribing all the data, and interpreting the results. The use of an auditor was the ma jor tool used to counteract researcher bias and increase the confirmability and credibility of the study. The auditor not only evaluated the research design she was indispensable in the interpretation of the results. This was done both independently to i mprove inter rater

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228 reliability, collectively, and contribution to this process significantly reduced threats to the credibility of the study. De spite the s e limitations, the results of this study do l end support to earlier studies regarding the existence of maladaptive schemas beyond body shape, weight and eating, in di sordered eating. The research supports the need to develop treatm ent protocols that address more maladaptive schema in treatment in o rder to decrease the risk of relapse in recovery. Future research is encoura ged to continue to explore the e ffect of maladaptive schema on disorde red eating in order to develop a ffective interventions in treatment.

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229 R eferences Agras, S. (1997). Hel ping people improve their lives with behavior therapy. Behavior Therapy 28, 375 384. A g r as, S., Walsh, T., Fairburn, C., Wilson, G., & Kraemer, H. (2000). A multicenter comparison of cognitive behavioral therapy and interpersonal psychotherapy for bulim ia nervosa. Archive General Psychiatry, 57, 459 466. America n Psychiatric Association. (2000 ). Diagnostic and statistical manual of mental disorders (4 th ed.). Washington, D.C.: Author. Anderson, D., & Maloney, K. (2001). The efficacy of cognitive behav ioral therapy on the core symptoms of bulimia nervosa. Clinical Psychology Review, 21, 971 988. Beam, M., Servaty Seib., H., & Mathews, L. (2004). Journal of Loss and Trauma, 9, 241 255. Bogdan, R., & Bilken, S., (2003). Qualitative Research for Education Boston, MA. Pearson Education Group, Inc. Byrne, S., Cooper, Z., & Fairburn, C. (2003). Weight maintenance and relapse in obesity: A qualitative study. International Journal of Obesity, 27, 955 962. Cente r for Disease Control and Prevention, Department of Health and Human Services (2009) Healthy weigh t: It is not a diet it is a lifestyle Re tr ie ved January 22, 2009 from http://www.cdc.gov/ccdphp/dnpa/healthyweight/ as sessing/bmi/index.htm

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230 C enter for Disease Control and Prevention, Department of Health and Human Services (2009) Over weight and obe sity R etrieved January 22, 2009 from http://www.cdc. gov/nccdphp/dnpa/obesity/defining.htm Cooper, Z., & Fairburn, C. (2001). A new cogni tive behavioral approach to the treatment of obesity. Behavior Research and Therapy, 39, 499 511. Cooper, M., Rose, K., & Turner, H. (2006). The specific content of co re beliefs and schema in adolescent girls high and low in eating disorder symptoms. Eating Behaviors, 7, 27 35. Creswell, J. (1998) Quality inquiry and research design, choosing among five traditions. Thousand Oaks, CA. Sage. Dingemans, A., Spinhoven, E ., and van Furth, E. (2006). Maladaptive core beliefs and eating disorder symptoms Eating Behaviors 7, 258 265. Europea n Food Information Council (2009 ). Retrieved May 21, 2009 from http://www.eufic.org/article/en/diet related diseases/obesity/expid/basics obesity overweight/ Fairburn, C., Cooper, Z., & Shafran, R. (2003). Cognitive behavior therapy for eating eory and treatment. Behavior Research and Therapy 41 509 528. psychological treatments for bulimia nervosa. Behav Res Ther, 24(6) 629 643. Fairburn, C., Shafran, R., & Cooper, Z (1998). A cognitive behavioral theory of anorexia nervosa. Behavior Research and Therapy, 37 1 13.

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231 Fairburn, C. & Wilson, F. (1993). Binge eating, nature, assessment, and treatment. NY, The Guil ford Press. Flegal, K., Carroll, R., Kuczmarski, R., & Johnson, C. (1998). Overweight and obesity in the United States: prevalence and trends, 1960 1994. International Journal of Obesity, 22 39 47. Garner, D. (1991). Eating disorder inventory 2: A professional manual. Odessa, FL: Psyc hological Assessment Resources. Hayaki, J., Friedman, M., & Brownell, K. (2002). Shame and severity of bulimic symptoms. Eating Behaviors, 3 73 83. Hughes, M., Hamill, M., van Gerko, K., Lockwood, R., & Waller, G. (2006). The relationship between different levels of cognit ion and behavioral ymptoms in the eating disorders. Eating Behaviors, 7, 125 133. Hurley, S., (2008). The Role of Early Maladaptive Schemas on Eating Disorders: A Case Study. Joiner, T. Heatherton, T., Rudd, M., & Schmidt, N. (1997). Perfectionism, perceived weight status, and bulimic symptoms: Two studies testing a diathesis stress model. Journal of Abnormal Psychology 106(1) 145 153. Jones, C., Harris, G., & Leung, N. (2005). Core beliefs and eating disorder recovery. Eu ropean Eating Disorders Review, 13 237 244. Katzman, D. (2005). Medical complications in adolescents with anorexia nervosa: A review of the literature. International Journal of Eating Disorders, 37, 52 59.

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232 Keel, P., Dorer, D., Franko, D., Jackson, S., Herzog, D. (2005). Post remission predictors of Relapse in women with eating disorders. The American Journal of Psychiatry, 162 (12), 2263 2268. Leung, N., & Price, E. (2007). Core beliefs in dieters and eating dis ordered women. Eating Behaviors 8 65 72. Leung, N., Waller, G., & Thomas, G. (2000). Outcome of group cognitive behavior therapy for bulimia nervosa: The role of core beliefs. Behavior Research and Therapy, 38, 145 156. Lincoln, Y., & Guba, E. (1985). Naturalistic Inquiry. N ewberry, CA. Sage Publications. Lundgren, J., Danoff Burg, S., & Anderson D. (2003 ). Cognitive behavioral therapy for bulimia nervosa: An empirical analysis of clinical significance. International Journal of Eating Disorders, 35, 262 274. Mehler, P., Crews, C., & Weiner, K. (2004). Bulimia: Medical complications. Journal 668 675. Meyer, C., Waller, G., & Watson, D. (2000). Cognitive avoidance and bulimic psychopathology: The relevance of temporal factor s in a nonclinical population. International Journal of Eating Disorders, 27 405 410. Miles, M., & Huberman, A. (1994). Qualitative Data Analysis. CA: Sage Publications, Inc. Neuman, P., & Ha l verson, P. (1983). Anorexia nervosa and bulimia: A handbook for counselors and therapists. NY: Van Nostrand Reinhold.

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233 Pervine, L., & John, O. (2001). Personality Theory and Research (8 th ed.). NY: JohnWiley & Sons, Inc. Plack, M. (2005). Human nature and research paradigms: Theory meets physical therapy practice, The Qualitative Report, 10(2), 223 245. Official Website of Polk County Florida retrieved May 4, 2009 from http://polkcounty.net/subpage.aspx?menu_id=8&nav= res&id=120 Patton, M. (1990). Qualitative evaluation and research methods (2 nd ed.) Newberry Park, CA: Sage Publications. Rogers, R., and Petrie, T. (1996). Personality correlates of anorexic symptomology in female undergraduates Journal of Counselin g & Development, 75, 138 144. Rogers R., and Petrie, T. (2001). Psychological correlates of anorexic and bulimic sym p tom ology. Journal of Counseling and Development, 79 178 187. Rose, K., Cooper, M., & Turner, H. (2006). The eating disorder belief que stionnaire: Psychometric properties in an adolescent sample. Eating Behaviors 7, 410 418. Sandelowski, M. (1995). Focus on qualitative methods: Sample size in qualitative research. Research in Nursing & Health, 18, 179 183. Schmidt, N., Joiner T., You ng, J., & Telch M (1995) The schema questionnaire: Investigation of psychometric properties and the hierarchical structure of a measure of maladaptive schemas. Cognitive Therapy and Research, 19 295 321. Seidman, I. (1991). Interviewing as qualitat ive research: A guide for researchers in education and the social sciences New York: Teachers College Press. Shiina, A., Nakazato, M., Mitsumori M., Koizumi, H., Shimizu, E., Fujisaki, M., & Iyo, M. (2005). An open trial of outpatient group therapy for bulimic disorders:

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234 Combination program of cognitive behavioral therapy and assertive training and self esteem enhancement. Psychiatry and Clinical Neurosciences 59 690 696. Spranger, S., Waller, G., & Bryant Waugh, R. (2001). Schema avoidance in bulim ic and non eating disordered woman International Journal of Eating Disorders, 29 302 306. Stake, R. (1995). The art of case study Thousand Oaks, CA: Sage Publications. Tyler, R., (2002) Coming out over a lifetime: A qualitative investigation of gay identity in the twenty first century (Doctoral dissertation). North Carolina State University, Raleigh, N.C. University of South Florida Polytechnic, 2009. FastFacts Retrieved May 4, 2009 from http://poly.usf.edu/AboutUs/FastFacts.html U.S. Census Bureau, State and County QuickFacts (2009). Retrieved May17, 2010 from http://quickfacts.census.gov/qfd/states/12/12105.html V a n Hanswijck de Jonge, P., Waller, G., Fiennes, A., Rashid, Z., & Lacey J.H. (2003). Reported sexual abuse and cognitive content in the morbidly obese. Eating Behaviors 4 315 322. Visscher, T., & Seidell, J. (2001). The public health impact of obesity. A nnual Review Public Health, 22 355 375. Waller, G. (2002). Schema level cognitions in patients with binge eating disorders: A case control study. International Journal of Eating Disorders. 33 458 464. Waller, D., Dickson, C., & Ohanian, V. (2002). Cognitive content in bulimic disorders core beliefs and eating attitudes. Eating Behaviors 3 171 178.

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235 Waller, Meyer, & Ohanian (2001). Psychometric properties of the long and short versions o f the Young schema questionnaire: Core beliefs among bulimic a nd comparison women. Cognitive Therapy and Research, 25 137 147. Waller, G., Ohanian, V., Meyer, C. & Osman, S. (1999). Cognitive content among bulimic women: the role of core beliefs. International Journal of Eating D isorders, 28 235 241. Wilson, N., & Blackhurst, A. (1999). Food advertising and eating disorders: Marketing body dissatisfaction, the drive, for thinness, and dieting in magazines. Journal of Humanistic Counseling, Education & Development 38 (2), 111 122. Wilson, G., & Fairburn, C. ( 1993). Cognitive treatment for the eating disorders. Journal of Consulting and Clinical Psychology, 61 261 269. Yin, R. (2003). Case study research: design and method (3 rd ). CA: Sage Publications, Inc. Young, J. (2003). Early Maladaptive Schemas and S chema Domains. Schema t herapy Retrieved October 8, 2007 from http://www.schematherapy.com/ id73.htm Young, J., Klosko, J., & Weishaar, M. (2003). New York, Gu ilford Press.

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236 Appendices

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237 A ppendix A Sample Recruitment Letter Date Re: Research on Eating Disorders Dear Student: I am a doctorate student at the University of South Florida in the Counselor Education program currently working o n my dissertation I am conducting a qualitative case study on the impact of maladaptive schema on disordered eating who are willing to volunteer a few hours of their time for an interviewing process If you have ever received a diag nosis of Anorexia Nervosa, Bulimia Nervosa or believe that your current weight would place you in the obese category based on the Body Mass Index and consider yourself a compulsive overeater, I would appreciate an opportunity to include you in my study. T hose who volunteer as part of the study would be afforded complete confidentiality. Your name and identity would not be used. The time you would spend in the interview would not be a therapeutic session. My goal would be to interview you no more than three times in order to gather as much information as possible regarding your thoughts and emotions associated with your disordered eating I would be happy to provide you with a copy of my proposal and answer any questions in advance of your joining my s tudy. Please feel free to contact me so that we may discuss my study and qualifications further. Sincerely, Susan Hurley, LMHC

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238 Appendix B Sample Recruitment Letter Date Name Address Re: Research on Eating Disorders Dear : I am a doctorate studen t at the University of South Florida in the Counselor Education program, and a Licensed Mental Health Counselor working on my dissertation For my dissertation I am currently conducting a qualitative collective case study on the impact of maladaptive sche ma on anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity. If you are currently seeing or have seen a patient diagnosed with anorexia, bulimia or would fit the Body Mass Index criteria for obese, not due to any medical reaso n I would appreciate an opportunity to include them in my study. This would not be a therapeutic session. My goal would be to interview the participant approximately four times in order to gather as much information as possible regarding their thoughts and emotions associated with their disorder. The first session would be to introduce the study to them and answer any questions they might have. They would then be asked to sign an Informed Consent t o Participate. The sessions would be recorded and tra nscribed by me and then I would ask each participant to revi ew the transcription for errors or additional information. All information will be held confidential and no names will be included in the written report.

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239 This study has been approved by the USF Institutional Review Board. I would be happy to provide you with a copy of my proposal and answer any questions in advance of your referring individuals to the study. Please feel free to contact me so that we may discuss my study and qualifications furth er. Sincerely, Susan Hurley, LMHC

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240 Appendix C Sample Questions This is a sample and not to be considered a complete list of questions. They are presented in no particular order Name:__________________ Date of Interview:____________________ Date of Bir th: ___________ Interview # _______ Information Gathering : Have you ever been treated for your eating disorder and if so what was the outcome? How do you feel about the outcome of your treatment? Describe yourself? Are there any words or phrases on the list you were provided that best describe how you think or feel about yourself? Describe your father? How would you characterize his personality? What effect do you see his personality and the description you have provided affecting you? Describe your mo ther? How would you characterize his personality? What effect do you see his personality and the description you have provided affecting you? Describe your siblings? How would you characterize his personality? What effect do you see his personality and the description have provided affecting you? Are there any other family members who you see having an affect on your life? Are there any words or phrases on the list you were provided that best describe how you think or feel about those family members? De scribe the beginning of your eating disorder. Where were you, how old were you, what type of events were taking place in your life?

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241 Bulimia How long have your binge and purge episodes been going on? Recall a first memory of this behavior? Was there a sp ecific event? What types of thoughts, activities, or feelings trigger your need to binge and purge? Did you try any of the coping skills you have learned in treatment to not binge and purge? What thoughts and feelings did you have at the time of this epis ode? What life events do you attribute to your eating disorder? What do you believe you gain from binging and purging? What do you believe you control from binging and purging? Obesity At what age do you recall being aware of being overweight? What diets, or eating plans have you tried to loose weight? What effect has your weight had on your life? What life events do you attribute to your eating disorder? Do any specific events, thoughts, and feelings cause you to eat more than normal? What do you believe y ou gain by eating? Anorexics: How long has it been since you last ate? What life events to you equate with your eating disorder, if any? What do you believe you gain by not eating? What do you believe you control by not eating?

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242 Appendix D Informed Conse nt to Participate in Research Information to Consider Before Taking Part in this Research Study Researchers at the University of South Florida (USF) study many topics. To do this, we need the help of people who agree to take part in a research study. This form tells you about this research study. We are asking you to take part in a research study that is called: The Impact of Maladaptive Schemas on Disordered eating: A Collective Case Study. The person who is in charge of this research study is S usan Hurley, LMHC Other research personnel who you may be involved include: Herbert A. Exum, Ph.D. The research will be done at the Univ ersity of South Florida Polytechnic Counseling Center, located on at 3433 Winter Lake Road, Lakeland, FL 33813. Pur pose of the study The purpose of this study is to help researchers understand how negative adjustment to play a role in disordered eating in order to find more successful treatment options. Study Procedur es If you take part in this study, you will be asked to attend 4 5 appointments to be interviewed by Susan Hurley, a Licensed Mental Health Counselor regarding your specific eating disorder and thoughts and feelings from your early childhood which may cont ribute to this eating disorder. You will be expected to keep a daily food journal, indicating when, and what you ate and what feelings or thoughts went along with eating, if any. These diaries may be used in the interview process to help both you and the interviewer to better understand how thoughts and feelings might trigger why people choose to eat or not eat. Each session will be audio recorded and typed word for word. You will have an opportunity to read your typed interviews and change anything wit hin your interviews that you believe may have not been clear or could be misunderstood. The sessions should not take more than 1 2 hours per week, and your part in the study should not take more than 3 months. The interviews and review of information wil l all take place at the office of Susan Hurley, LMHC at the Univ ersity of South Florida Polytechnic Counseling Center.

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243 Alternatives You may choose not to participate in this research study. Benefits art in this study. Risks or Discomfort There are no known risks to those who take part in this study. Compensation We will not pay you for the time you volunteer while being in this study Confidentiality We must keep your study records confidential. All audio tape recordings, food this counselor will have the only key. The records for this study will be kept separate from client files and student records. Th e records will be identified by number only and all tapes, diaries and research notes will be identified with the same number. The list of numbers applied to each participants name will be keep separate from the research files. The identity of the partic ipants will be known to the researcher only. Once the audio tapes have been transcribed and approved by the participant for accuracy, the tapes will be destroyed. The transcriptions of the audio tapes may be reviewed by another researcher, however, that person or persons will not have access to your identity. The up to three (3) years at which time all the records will be destroyed. However, certain people may need to see your study records. By law, anyone who l ooks at your records must keep them completely confidential. The only people who will be allowed to see these records are: The research team, including the Principal Investigator, study coordinator, a nd all other research staff Certain government and university people who need to know more about the study. For example, individuals who provide oversight on this study may need to look at your records. This is done to make sure that we are doing the stud y in the right way. They also need to make sure that we are protecting your rights and your safety. These include: o the University of South Florida Institutional Review Board (IRB) and the staff that work for the IRB. Other individuals who work for USF t hat provide other kinds of oversight may also need to look at your records. o the Florida Department of Health, people from the Food and Drug Administration (FDA), and people from the Department of Health and Human Services (DHHS)

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244 We may publish what we learn from this study. If we do, we will not let anyone know your name. We will not publish anything else that would let people know who you are. Voluntary Participation / Withdrawal You should only take part in this study if you want to volunteer. Yo u should not feel that there is any pressure to take part in the study, to please the investigator or the research staff. You are free to participate in this research or withdraw at any time. There will be no penalty or loss of benefits you are entitled to receive if you stop taking part in this study. Your decision to participate or not to participate will not affect your student status (course grade) or job status. Questions, concerns, or complaints If you have any questions, concerns or complaints abo ut this study, call Susan Hurley, LMHC at 863 667 7046. If you have questions about your rights, general questions, complaints, or issues as a person taking part in this study, call the Division of Research Integrity and Compliance of the University of Sou th Florida at (813) 974 9343. If you experience an adverse event or unanticipated problem call Susan Hurley, LMHC at 863 667 7046. If you have questions about your rights as a person taking part in this research study you may contact the Florida Departmen t of Health Institutional Review Board (DOH IRB) at (866) 433 2775 (toll free in Florida) or 850 245 4585. Consent to Take Part in this Research Study It is up to you to decide whether you want to take part in this study. If you want to take part, please sign the form, if the following statements are true. I freely give my consent to take part in this study. I understand that by signing this form I am agreeing to take part in research. I have received a copy of this form to take with me. S ignature of Person Taking Part in Study Date Printed Name of Person Taking Part in Study Statement of Person Obtaining Informed Consent I have carefully explained to the person taking part in the study what he or she can expect. I hereby certi fy that when this person signs this form, to the best of my knowledge, he or she understands:

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245 What the study is about. What procedures/interventions/investigational drugs or devices will be used. What the potential benefits might be. What the known risks might be. I also certify that he or she does not have any problems that could make it hard to understand what it means to take part in this research. This person speaks the language that was used to explain this research. This person reads well enoug h to understand this form or, if not, this person is able to hear and understand when the form is read to him or her. This person does not have a medical/psychological problem that would compromise comprehension and therefore makes it hard to understand w hat is being explained and can, therefore, give informed consent. This person is not taking drugs that may cloud their judgment or make it hard to understand what is being explained and can, therefore, give informed consent. Signature of Person Obtaining Informed Consent Date Printed Name

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246 Appendix E Journal Log Date Time Food Binge Purge Feelings Comments

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2 47 A ppendix F Words and Phrases Most Often Associated With Maladaptive Schema Unreliable Unstable Unprotected Unpredictable Abandoned Hurt Abused Humiliated Cheated Lied Manipulated Taken a dvantage of Absence of a ttention Lack of a ffection Lack of warmth Lack of companionship Lack of understanding Not listened to Unprotected Lack of guidance Defective Bad Unwanted Inferior Unlovable Criticized Rejected Blamed Self c onscious Insecure Shame Isolated Different from other people N ot part of a group or community Take care of self Solve daily p roblems Exercise good j udgment Tackle new tasks Make good d ecisions Helpless Fear Over involvement in other lives No life of my own Lack of separate identity Fear of decision making Need to give in to others wishes Allow partner to make all important decisions Let others make decisions for me Do not stand up for self Inadequate Failure Stupid Inept Untalented Ignorant Lower in Status Less successful than others E ntitlement A feeling of superiority For cing ones point of view on others Controlling behavior of others Lack of empathy for others Lack of self control Avoid pain Avoid conflict Avoid confrontation Avoid responsibility Suppression of my desires and needs

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248 Suppression of anger Suppression of ot her emotions My feelings and emotion do not count Feeling trapped need Need to gain approval Need to gain recognition My self esteem is dependent on how others see me Pessimistic Fear of making mistakes Worrie d Over vigilance Complainer Indecisive Lack of spontaneity Insecurity to show joy, affection Insecurity to show sexual excitement Insecurity to show vulnerability Insecurity to express feelings Insecurity to express needs Perfectionism Inordinate attentio n to detail Hypercritical toward self Rigid rules High moral percepts High ethical percepts High religious percepts Preoccupation with time Tendency to be intolerant Tendency toward anger Tendency toward impatience Lack of forgive ness for mistakes (self/o thers)

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249 Appendix G Coding Cathy Compulsive Overeater/Obesity Category Definition Participant Statement Abandonment/Instability (AB) The perceived instability or unreliability of those available for support and connection. Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable, unreliable, or erratically present; because they will die imminently; or because they will abandon the patient in favor of someone better. I think he draws himself away from everything and that is when he falls out of our liv e s my brothers and my lives. I went through a divorce with my first husband. He was just running a round all the time I want the mom and the dad to wake up with the babies because that is all I ever wanted as a kid. Defectiveness/Shame (DS) The feeling that one is defective, bad, unwanted, inferior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involved hypersensitivity to criticism, rejection, and blame; self consciousness, comparisons, and insecurity around others; or a sense of shame may be priva te (e.g. selfishness, angry impulses, unacceptable sexual desires) or It is almost to the point where he had demons. I felt like as a child and even grown up today that he has demons. Or a devil has just taken over his body because he is not a good person when he is on drugs and drinking. Defective, I see the word right there. There are some other ones but defect ive is definitely the word.

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250 public (undesirable physical appearance, social awkwardness). And on the bad part, just low self esteem and it is just putti ng yourself down a lot I am not good enough. Sometimes I feel like I am driving down the road, with no Bluetooth in my ear or anything just talking and hoping no one is looking at me like I am craz y. w ould feel bad about myself. would put her down. So I think seeing that I then internally was puttin g that in my own mind. I felt like I am not a good mom because my kids a all apart and I I c ould have done this better. What is wrong with me. I cry a lot, and t hen put myself down inside. I was sitting there crying and I am just shoveling piles in my mouth and all of a sudden I realized oh my gosh almost the whole bag was gone and I

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251 op ened the bag. And I said, what is wrong with you? What is seriously wrong with you? So I know that there is something inside saying ctive. I love you honey and you are not overweight. If I could be your size. And I am thinking mom that is beautiful but that is not helping me at all because I do I would say an outside looking in they would say Cathy is very successful. Cathy says this is luck. And why are they pi cking me for all these Dependence/Incompete nce (DI) everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). Of ten presents as helplessness. And at that point I thought he loves me no matter have anybody telling me I wish this or that like my mom and dad. This is the second time I have been married and I am fai ling. What is wrong with me? And so finally my husband said you need to do something and we finally came to the decision to move forward and we got it done. It is always good to have someone to do it with.

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252 Right now my friend is joining me in the gym and we are putting together our plans of what we are going to eat and really paying attention to that. So I think her and I together can make it work because she lost a lot of weight too when we did it together. I would surround myself with people and say look if I do this you got to say something to me. My best knock it off. We had this understanding. She never had to hit me. I got it. Emotional Deprivation (ED) r a normal degree of emotional support will not be adequately met by others. The three major forms of deprivation are: A. deprivation of Nurturance: Absence of attention, affection, warmth, or companionship. B. Deprivation of Empathy: Absence of under standing, listening, self disclosure, or mutual sharing or feelings from others. C. Deprivation of Protection: Absence of strength, direction, or guidance from others. [Mom] loves her children puts them first over anybody. It is so much to a point whe re she forgets her grandchildren. I think she does that only because she has guilt for how we were raised in the family and so she is trying to make it up to us not realizing that what we really want is the love for our children t hat would make me happy is very factual and does not want to hear that fluff stuff. He likes to pick on me He likes to push my buttons and get me all riled up. [ Enmeshment (EM) Excessive emotional involvement and So kin d of I am living through her and doing those

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253 closenes s with one or more significant others (often parents), at the expense of full individuation or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of th e other. May also include feelings of being smothered by, or fused with, others or insufficient individual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme cases questioning things with her you know probably doing a little bit more than I should. Entitlement (ET) The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interactions. Often involves insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on sup eriority (being among the most successful, famous, wealthy) in order to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward, or domination of point of view, or controlling the behavior of without

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254 feelings Insufficient Self Control (IS) Pervasive difficulty or refusal to exercise sufficient self control and frustrat ion tolerance impulses. In its milder form, patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict, confrontation, respo nsibility, or overexertion at the expense of personal fulfillment, commitment, or integrity. It is w hat makes me feel good. I like comfort food It works for a minute then you are uncomfortable as was so desperate to do something without realizing that the real issue was within me. I cried every day, I ate, I ate late, super late because Sometimes two or three in the morning so I would be eating, and that is not a good time to eat certainly, but that was the comfort. It is a glass of milk and some cookies or pie s itting there watching television. Mistrust/Abuse (MA) The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually in volves the perception that the harm is intentional or the result of unjustified and extreme negligence. May include the sense that one always ends up being He was manipulative in getting things his way. Twisting it toward where it w orked out to his benefit He loves them so much and there is never a doubt when my daughter sits on his lap. the case for me. I would question wh at is

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255 happening here Subjugation (SB) Exces sive surrendering of control to others because one feels coerced usually to avoid anger, retaliation or abandonment. The two major forms of subjugation are: A. Subjugation of Needs: Suppression of B. Subjuga tion of Emotions: Suppression of emotional expression, especially anger. desires, opinions, and feelings are not valid or important to others. Frequently presents as excessive compliance, combined with hype rsensitivity to feeling trapped. Generally leads to a build up of anger, manifested in maladaptive symptoms (e.g., passive aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal Social Isolation/Alienation (SI) The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community. Self Sacrifice (SS) Excessive focus on voluntarily meeting the needs of others in da ily situations, at the common reasons are: to prevent causing pain to others; to avoid guilt from feeling selfish; or to maintain the connection with others perceived I have seen people all my life who say that is a mean per son. I have never wanted to be that person that someone speaks at the dinner table about. Have I not liked people? Absolutely but they would never know it dealing with them because I just have always believed that

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256 as needy. Often results from an acute sens itivity to the pain of others. Sometimes being adequately met and to resentment of those who are taken care of. (overlaps with sense of co dependency) Personality wise I can walk up to a g roup of people and just chit chat about whatever and pick up very quickly what interests them and then have a conversation around that and I may not know anything about it. Emotional inhibition (EI) The excessive inhibition of spontaneous action, feeling or communication usually to avoid disapproval by others, feelings of shame, or common areas of inhibition involve: (a) inhibition of anger & aggression, (b) inhibition of positive impulses (e.g. joy, affectio n, sexual excitement, play); (c) difficulty expressing vulnerability or communicating freely about emphasis on rationality while disregarding emotions. This is what makes me feel good. Li ke the comfort food. All I know is that I at e and it made me feel good. I would be eating, and that is not a good time to eat certainly but that was the comfort. I would comfort myself going through that v ery serious depression Q: And then go eat anyway? A: Yes I eat any way. I was sitting there crying and I am just shoveling piles in my hand, and all of the sudden I looked down and realized oh my gosh almost the whole bag was gone, and I opened the bag. outside, and the hurt of the heart and say all right if my stomach is hurting like crazy then it takes everything else away.

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257 Q: Do any specific events cause you to eat more than others? A: Probably just an y type of low moment. Q: What do you think you gain by eating ? A: Just feeli ng good at that moment. Failure to achieve (FA) The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to career, sports, etc). Often involves beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc. I felt like I am not a good mom because my kids are know this and that. You pick apart all the things you do in the whole marriage and you think I could have done this better. I would say an outsider looking in would say Cathy is very successful. Cathy says it is luck When I got divorced my thoughts were I am just not good enough. What it says about me i s that I failed. This is the second time I am married and I am failing at it. I put it all on myself. Maybe this is your fault. Everything points to you. Unrelenting standards/Hyper criticalness (US) The underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid I want the mom and the dad to wake up with the babies because that is all I ever wanted as a kid. I want the mother and the father and the children all

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258 criticism. Typically results in feelings or pressure or difficulty slowing down; and in hypercriticalness toward oneself and others. Most involve significant impairment in: p leasure, relaxation, health, self esteem, sense of accomplishment, or satisfying relationships. Unrelenting standards typically present as (a) perfectionism, inordinate attention to detail, or performance is relative to the norm; (b) rigid including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that more can be accomplished. together under one roof. He is a great father. I could not ask for any person better. Sometime it makes me angry at him because I wanted t h at, I wanted that life. Vulnerability to harm (VH) Exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the following: (a) medical catastrophe: e.g., heart attacks, AIDS; (b) emotional catastrophes e.g., going crazy (c) external catastrophes; e.g. elevators collapsing, victimized by criminals, airplanes crashes, earthquakes. Approval seeking/Recognition seeking (AS) Excessive emphasis on gaining approval, recognition, or attention from other people, or fitting in, at the expense of developing a secure If I die I want to be fun, happy, I want everyone to have a party and say man that girl was the coolest

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259 dependent primarily on the reactions of others Sometimes includ es an overemphasis on status, appearance, social acceptance, money, or achievement as mean of gaining approval, admiration, or attention (not primarily for power or control). Frequently results in major life decisions that are inauthentic or unsatisfyin g; or in hypersensitivity to rejection. person in the world, or the neatest person, most int eresting or something. And I like being around people so being the group settings and bragging and saying yeah, I did it too and look wha t we can do together. I want people to see me as successful So it is like I really, really care about what people think o f me. Almost too much. Even today I care about wh at people think about me in the s ense of my reputation. whatever it may be. Negativity/Pessimism (NP) A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflic t, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc) while minimizing or neglecting the positive or optimistic aspects. Usually includes an exaggerated expectation in a wide range of work, financial, or interpersonal situations that things will ultimately fall apart. Usually Punitiveness (PU) The belief that people should be harshly

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260 punished for mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with those people (incl uding oneself) who do Usually includes difficulty forgiving mistakes in oneself or others, because of a reluctance to consider extenuating circumstances, allow for human imperfection or empathize with feelings.

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261 Appendix H Coding Joan Compulsive Overeater/Obesity Ca tegory Definition Participant Statement Abandonment/Instability (AB) The perceived instability or unreliability of those available for support and connection. Involves the sense that sign ificant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable, unreliable, or erratically present; because they will die imminently; or becaus e they will abandon the patient in favor of someone better. When I was younger she was always dating a lot. And she made it her personal mission to find me a pushing me away by not spending time with me. I f elt rejected because she was working so hard at tting any attention. til I started counseling. Defectiveness/Shame (DS) The feeling that one is def ective, bad, unwanted, inferior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involved hypersensitivity to criticism, rejection, and blame; self consciousness, comparisons, and insecurity around ot hers; or a sense of shame may be private (e.g. selfishness, angry impulses, unacceptable sexual desires) or public (undesirable physical appearance, social t I knew I was different than other kids. I remember having low self esteem when I was a kid because of some of the same reasons. It probably started when I was in kindergarten or first grade that I started having doubts about my self esteem and about th e way I looked because all the different from the other girls. And I remember even

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262 awkwardness). girls making fun of me when I was younger and calling me fat and saying thin gs like that. My back was curved and my stomach poked out a confid ence in myself because of that. I have issues with my weight and fee ling bad about myself. ha ve because of my ethnicity My whole life I thought if I am skinny I will be so have braces, and I was skinny I will be so happy. If I could get rid of all those things at the same time then th ings wo uld be great. I remember being more paranoid about my self esteem because I thought, well I finally look pretty now its got to be something I am doing wrong with me instead. Because if you are overweight you can personal. But if you feel like you look really pretty that attention it is like wait a second t

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263 make sense My step grandmother embarrassed me in front of the whole family basically and so ever since then I said can we take home a wate to pee all over the bed, in front of everybody Her daughter was there and I go upset and she came to talk to me later and blamed me for it and she said ab out it. It is you fault. When I get half way through the semester I get so depressed and hopeless and I want to give up every t I am not good at it. e is doing better than me. That you are never good enough. That you will pe ople who are like that So I think it does impact your self esteem a lot if

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264 be something wrong with you. And you are not as pre t ty as everybody else Dependence/Incompetence (DI) everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). Often presents as helplessness. Emotional Deprivation (ED) degree of emotional support will not be adequately met by others. The three major forms of deprivation are: A. deprivation of Nurturance: Absence of attention, affection, warmth, or companionship. B. Deprivation of Empathy: Absence of understanding, listening, self disclosure, or mutual sharing or feelings from others. C. Deprivation of Protection: Absence o f strength, direction, or guidance from others. I did have a lot of baby sitters when I was little. Any my mom she worked full time. She would come home and on Sunday she would sleep all day. And I remember watching TV because that would keep me busy. I remember waking my mom up a lot. Hey mom can I eat the Doritos? And she would say no you can have a bowl of cereal. And I would be like please, please can I eat the Doritos. And I remember eating a lot. I would have a little carpet picnic and eating really know how much it was. it may have been like three or four bowls of cereal over five hours So I think it really impacted me a lot no t having my dad around. Enmeshment (EM) Excessive emotional involvement and closen ess with one or more significant others (often parents), at the expense of full individuation or normal social development. My m om has always neede d my help. She constantly asked for my help. I d have a choice.

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265 Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. May also include feelings of being smothered by, or fused with, others or insufficient individual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme cases questioning remember eating that and drinking diet coke for lunch because that is what my mom drank a nd that is what we had a t home. When I was younger it seemed like she always and say oh mom you are not fat or you are pretty or I love you. Or you start to take it out on yourself and say well if my mom thinks that then maybe th at is what I should do. You start to think it is normal and you start to do it to yourself. And I realize I do that to myself Probably if she has told me once she has told me a million times that I am the most important thing in the world to her. And anything to ever happen to me and that nobody is going to ever h urt me no matter what. Q: You said we feel better, we find happiness in food. A: Me and my mom. Whenever I asked her a question she would always tell me the truth no m atter how difficult it was or her. Or she would tell me I will tell you in a few

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266 years. But I remember that being so different from m y mom about anything. I remember us talking about it for about thr ee hours straight crying. And it was so exhausting trying to have a conversation and trying to understand her point of view because in her mind she had tried to protect me during this whole, during my whole life and it was like I was throwing that in her face if I wan ted to meet him anyway My grandmother is someone we have both avoided. more to tell the truth I think we have gotten to the point where we kind of like our privacy and we are happy where we are. (473 4 75) way we Entitlement (ET) The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interactions. Often involves insistence that one should be able to do or have whatever one wants, regardless of what is

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267 realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on superiority (being among the most successful, famous, wealthy) in order to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward, or domination of point of view, or controlling t he behavior of without feelings Insufficient Self Control (IS) Pervasive difficulty or refusal to exercise sufficient self control and frustration tolerance personal goals, or to restrain impulses. In its milder form, patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion at t he expense of personal fulfillment, commitment, or integrity. Mistrust/Abuse (MA) The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually involves the perception that the harm is intentional or the res ult of unjustified and extreme negligence. May include the sense that one always ends up being him. Just to meet him once just to see what he was like. But I was kind of scared because what if he is not what I expect. What if he is not a nice person? And then all of those fears that I have of being associated with someone that is not a good person

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268 would come true. And then I would start to internalize that and say well if he is like that and he is half of me what does that make me My mom always tried to be really careful with me and would say you need to always be aware of your surroundings and you need to be careful. I remember her als o saying something about it someone is looking at you, look them in the eye because that means they know you are not someone who is shy. I was unsure about that. And I was also unsure me to be around? I have a lot of trust issues with guys because my dad that were around my mom I thought the only reason they were around her was because they wanted something. I thought they jus t wanted her for sex. tionship and because I had never had a really positive male struggle with it. Trying to understand how there are good guys out there but so many of them are bad. It is just c omplicated sometimes. Sub jugation (SB) Excessive surrendering of control to others

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269 because one feels coerced usually to avoid anger, retaliation or abandonment. The two major forms of subjugation are: A. Subjugation of Needs: Suppression of esires. B. Subjugation of Emotions: Suppression of emotional expression, especially anger. desires, opinions, and feelings are not valid or important to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Generally leads to a build up of anger, manifested in maladaptive symptoms (e.g., passive aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal people where your dad is from. And I think in her mind she was trying to protect me because the town she grew up in was very prejudice. And I think in ce the same prejudice that she may have faced or others may have faced. And so she was trying to protect me but and it was so confusing for me. Well how is it that I am not suppose to be ashamed of who I am but I am not suppose to tell anybody where my dad is from but he is not bad. I never got want him to find us and take you away. Social Isolation/ Alienation (SI) The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community. Well I think that I felt different from everybody. All the other girls were skinny and they could shop in the skinny girls sections. I remember having to rts that would fit my bottom. Self Sacrifice (SS) Excessive focus on voluntarily meeting the needs of others in daily situations, a t the common reasons are: to prevent causing pain to

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270 others; to avoid guilt from feeling selfish; or to maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pa in of others. Sometimes being adequately met and to resentment of those who are taken care of. (overlaps with sense of co dependency) Emotional inhibition (EI) The excessive inhibition of spontaneous action feeling or communication usually to avoid disapproval by others, feelings of shame, or common areas of inhibition involve: (a) inhibition of anger & aggression, (b) inhibition of positive impulses (e.g. joy, affection, sexual excitement, play); (c) difficulty expressing vulnerability or communicating freely about emphasis on rationality while disregarding emotions. When I was little I think it was more boredom tha n anything. No I think a lot of emotions. I mean when I get upset. We rel ate food to happiness. Food brightens my day. If I am having a bad day and I find out there is free food on campus I am like, free food, yes! My day just got better. But that i s something that is really important to me and makes me feel better. If I am really upset and eat certain food s I usually feel better. I do know that if I have a bad day at work or I am really stressed out or I am in a really bad mood I will eat. Or a l ot of times when I am home and see something good on TV or I am bored I eat. I think that when you eat you get those feelings of happiness and you feel so much better. Failure to achieve (FA) The belief that one has failed, will inevitably I would think that I was d oing really good and it

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271 fail, or is f undamentally inadequate relative to career, sports, etc). Often involves beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc. would say I went over my limit all the time. And I was trying to che ck from. And the exercises I did progress so I stopped using it. Unrelenting standards/Hyper criticalness (US) The underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criticism. Typically results in feelings or pressure or difficulty slowing down; and in hypercriticalness toward oneself and others. Most involve significant i mpairment in: pleasure, relaxation, health, self esteem, sense of accomplishment, or satisfying relationships. Unrelenting standards typically present as (a) perfectionism, inordinate attention to detail, or performa nce is relative to the norm; (b) rigid including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that more can be accomplished. When I got ol der I started exercising. I would do pushups and sit ups for 30 minutes a night. I would test myself all the time to make sure my abs were tight. I remember b eing pre occupied with that.

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272 Vulnerability to harm (VH) Exaggerated fear that imminent catast rophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the following: (a) medical catastrophe: e.g., heart attacks, AIDS; (b) emotional catastrophes e.g., going crazy (c) external catastrophes; e.g. elevator s collapsing, victimized by criminals, airplanes crashes, earthquakes. Approval seeking/Recognition seeking (AS) Excessive emphasis on gaining approval, recognition, or attention from other people, or fitting in, at the expense of developing a secure and dependent primarily on the reactions of others Sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievement as mean of gaini ng approval, admiration, or attention (not primarily for power or control). Frequently results in major life decisions that are inauthentic or unsatisfying; or in hypersensitivity to rejection. Partly I think I loved it because you are in the club now b ecause everyone is working out and talking about their gym and I could say I go to the gym. And it was just fun to be one of those people. accepting who you are no matter what size you are and having confidence. And it is really hard to have you are worried about how other people perceive you and those types of things. really thought I was trying to find one to identify with. I wish I could marry an Italian or American Indian or some other culture that I look like that I can

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273 so outed or that there is something wrong with me because I am a part of a cul ture tha t nobody likes. I was always the bigger person in the group. And different. You want to be accepted and you want to be able to buy the clothes that everyone else is wea ring and that was hard Negativity/Pessi mism (NP) A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc) while minimizing or neglecting the posi tive or optimistic aspects. Usually includes an exaggerated expectation in a wide range of work, financial, or interpersonal situations that things will ultimately fall apart. Usually Punitiveness (PU) The belief that people should be harshly puni shed for mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with those people (including oneself) who do Usually includes difficulty forgiving mistakes in oneself or others, because of a reluctance to consider extenuating circumstances, allow for human imperfection or empathize with feelings.

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274 Appendix I Coding Laura Compulsive Overeater/Obesity Category Definition Participant Statement Abandonment/Instability (AB) The perceived instability or unreliability of those available for support and connection. Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emot ionally unstable and unpredictable, unreliable, or erratically present; because they will die imminently; or because they will abandon the patient in favor of someone better. Defectiveness/Shame (DS) The feeling that one is defective, bad, unwanted, inf erior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involved hypersensitivity to criticism, rejection, and blame; self consciousness, comparisons, and insecurity around others; or a sense of shame regarding were always on the buy food than to cook I tire easily. I am tired most of the time. I take so much stuff just to stay up I am so disappointed with myself.

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275 be private (e.g. selfishness, angry impulses, unacceptable sexual desires) or public (undesirable physical appearance, social awkwardness). But you know I feel like if I am this size when I finish school I will be discriminate d again st trying to get a job my kids like I want I feel disappointed in myself that I am at this age I have not achieved what it was I set out to ac hieve by a certain age And so I am really di sappointed wi th myself. I felt unwanted, inferior, criticized, reje cted, blamed and insecure. I think I just mental ave any true strengths. never have completed anything bu t high school and that was because I had to. Dependence/Incompetence (DI) everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). My world revolved around him and there was no more going out with the girls because they were single and so it was no more going to the gym. He came into the picture and had an extra

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276 Often presents as helplessness. uch anymore (husband). moved back down here where we had h elp from my parents. Emotional Deprivation (ED) l degree of emotional support will not be adequately met by others. The three major forms of deprivation are: A. deprivation of Nurturance: Absence of attention, affection, warmth, or companionship. B. Deprivation of Empathy: Absence of understanding, listening, self disclosure, or mutual sharing or feelings from others. C. Deprivation of Protection: Absence of strength, direction, or guidance from others. I felt a lack of affection, and lack of understanding, tha She [Mom] wa s sleeping with two men. She was married. But my birth certificate says that was still married I had his last name up until I was eight. And then she moved in with my current father. When they would go off for the weekends they would send the whole family over to stay with her former husband. And then when they moved into a bigger home in a anymore with the other kids to see their father They made me say he i s my dad all my life. drank he was very abusive both physically and mentally. If he was angry he wanted everyone in the house to be angry. I would try to hide in

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277 my room and he would literally come back there and tell me to come out of my room ad sit out in the front and be around him while he was angry. When I first started gaining weight he said he would pay me a thousand dollars to anymo re I felt a lack of affection and lack of understanding t Enmeshment (EM) Excessive emotional involvement and closeness with one or more significant others (often parents), at the expense of full individuation or normal s ocial development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. May also include feelings of being smothered by, or fused with, others or insufficient indivi dual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in existence. If something happens to one of use it happens to both of us. We are not separate. My world revolved around him. Entitlement (ET) The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of

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278 reciprocity that guide normal social interactions. Often involves insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on superiority (being among the most successful, famous, wealthy) in order to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward, or domination of desires without empathy or concern for Insufficient Self Control (IS) Pervasive difficulty or refusal to exercise sufficient self control and frustration or to restrain the excessive expression or ulses. In its milder form, patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion at the expense of personal fulfillment, commitment, or integrity. When you get bored to do and you just knick knack all day long. I mean I would open up the pack and eat it all I find it hard to just fight off just eating something.

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279 Mistrust/Abuse (MA) The expectation that others will hurt, abuse, humiliate, ch eat, lie, manipulate, or take advantage. Usually involves the perception that the harm is intentional or the result of unjustified and extreme negligence. May include the sense that one always ends up being cheated relative t end of the He was one of those people that would say things that only your enemy would say like, he would call me names. He called me ugly, slut, come out of his mouth. He called me fat. If I gained a little weight he would say things like you are unattractive and this and that. He was horrible. It was like he would lose interest and when he did he would publicly embarrass me. We were out at a function and he poured a 64 oz orange soda on my head. He would make statements. th physically and mentally. Q: When he does it, does he still become abusive? A: Yes I get away from him then He was pretty much just as abusive as my boyfriend. And he called me n ames. He would call me a slut and whore and tell me I was doing this and that and I a m telling him I am not. They made me sa y he is my dad all my life.

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280 At one point I felt like I gained weight so he not be ap pealing to him anymore He would come to visit and I would stand in to go outside. And if I did go outside I would get beat or what have you When he moved up there with me and that was the worst time of my life. That is when I had enough because it was cons tant non stop with him He would do things like not come home and then blame me for when he did get there. I was li ke how was it my fault. Subjugation (SB) Excessive surrendering of control to others because one feels coerced usually to avoid anger, retaliation or abandonment. The two major forms of subjugation are: A. Subjugation of Needs: Suppression of B. Subjugation of Emotions: Suppression of emoti onal expression,

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281 especially anger. Usually involves the opinions, and feelings are not valid or important to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Gener ally leads to a build up of anger, manifested in maladaptive symptoms (e.g., passive aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal of Social Isolation/Alienation (SI) Th e feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community. I would tell my mom some things but then I involve family in everything about yo ur relationship because when you forgive him your parents still remember. So I learned from that not to involved them in that. So it was pretty much I have been a lon er most of my whole life. people your busin ess. What happens at home stays home and Black women have to be else to help y ou with your problems. Self Sacrifice (SS) Excessive focus on voluntarily meeting

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282 the needs of others in daily situations, at the e The most common reasons are: to prevent causing pain to others; to avoid guilt from feeling selfish; or to maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pain of o thers. needs are not being adequately met and to resentment of those who are taken care of. (overlaps with sense of co dependency) Emotional inhibition (EI) The excessive inhibition of spontaneous action, feeli ng or communication usually to avoid disapproval by others, feelings of shame, or losing control of of inhibition involve: (a) inhibition of anger & aggression, (b) inhibition of positive impulses (e.g. joy, affect ion, sexual excitement, play); (c) difficulty expressing vulnerability or feelings, needs, etc., or (d) excessive emphasis on rationality while disregarding emotions. So I try not to get into those feelings that will lead m e to depression or things of that nature. affected but it just hu rt my esteem too much. Q: Do you know what you are really looking d. A: No it is not food, but right now my financial situation, with the means to do what I am in the mood to do. No w ords would come out. I had had enough. I had gotten to my breaking point and that was

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283 enough for me. So I try not to get into those feelings that will lead me to depression or things of that nature. beneficial to anyone if I am unhappy. Failure to achieve (FA) The belief that one has failed, will inevitably fail, or is fundamentally of achievement (school, career, sports, etc). Often involves beliefs that one is stupi d, inept, untalented, ignorant, lower in status, less successful than others, etc. I feel disappointed with myself that I am this age and I have not achieved what I set out to achieve W believed in mysel f in anything, and I have never completed anything but high school and that was because I had to Unrelenting standards/Hyper criticalness (US) The underlying belief that one must strive to meet very high internalized standards of behavior and performance usually to avoid criticism. Typically results in feelings or pressure or difficulty slowing down; and in hypercriticalness toward oneself and others. Most involve significant impairment in: pleasure, relaxation, health, self esteem, sense of accomplish ment, or satisfying relationships. Unrelenting standards typically present as (a) perfectionism, inordinate attention to

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284 detail, or an underestimate of how good many areas of life, including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that more can be accomplished. Vulnerability to harm (VH) Exaggerated fear that imminent catastrophe will strike at an y time and that one will be unable to prevent it. Fears focus on one or more of the following: (a) medical catastrophe: e.g., heart attacks, AIDS; (b) emotional catastrophes e.g., going crazy (c) external catastrophes; e.g. elevators collapsing, victimize d by criminals, airplanes crashes, earthquakes. Approval seeking/Recognition seeking (AS) Excessive emphasis on gaining approval, recognition, or attention from other people, or fitting in, at the expense of developing a secure and true sense of self. O primarily on the reactions of others rather Sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievement as mean of gaining approval, admiration or attention He was the first person to ever really open up and talk to me and want to know abo ut me. I was pudgy in middle school and no one looked at me but then I went to high school and everyone saw me. But he paid the most attention to me. He was the first one who wanted to know who I was. I was always a pleaser.

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285 (not primarily for power or control). Frequently results in major life decisions that are inauthentic or unsatisfying; or in hypersensitivity to rejection. Negativity/Pessimism (NP) A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc) while minimizing or neglecting the positive or o ptimistic aspects. Usually includes an exaggerated expectation in a wide range of work, financial, or interpersonal situations that things will ultimately fall apart. Usually Punitiveness (PU) The belief that people should be harshly punished for m istakes. Involves the tendency to be angry, intolerant, punitive, and impatient with those people expectations or standards. Usually includes difficulty forgiving mistakes in oneself or others, because of a reluc tance to consider extenuating circumstances, allow for human imperfection or empathize with feelings.

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286 Appendix J Coding Margaret Compulsive Overeater/Obesity Category Definition Participant Statement Abandonment/Instability (AB) The perceived instability or unreliability of those available for support and connection. Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally un stable and unpredictable, unreliable, or erratically present; because they will die imminently; or because they will abandon the patient in favor of someone better. After my parents got divorced we lived in our little apartment. My mom had to work and I was a latch key kid and I remember it was a Christmas holiday. It was like the week before Christmas and we work and so I am in the apartment. And I just remember feeling for the first time in my life f eeling profoundly alone. My mom was 25 when she got divorced and she was still pretty young and cute and she wanted to night but she used to leave me alone a lot. She would come home from work and check to see that I had a bath and everything and then she would get ready and she would say is 9:00 and you need to get to bed. Defectiveness/Shame (DS) The feeling that one is defective, bad, unwanted, inferior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involved My mother showed me how to dial for help on the phone so that the next time he beat her I coul d call for help. It just happened that the next time he beat her it was so severe that I just froze. I was just

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287 hypersensitivity to criticism, rejection, and blame; self consciousness, comparisons, and insecurity around others; or a sense of shame s. These flaws may be private (e.g. selfishness, angry impulses, unacceptable sexual desires) or public (undesirable physical appearance, social awkwardness). standing there with the phone in my hand. I remember the beatings. I remember how he use to choke her. I remember that incident with the ph one being one of the most sha meful things of my life. Dependence/Incompetence (Dependence/Incompetence) everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of o neself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). Often presents as helplessness. Emotional Deprivation (ED) degree of emotional support will not be adequately met by others. The three major forms of deprivation are: A. deprivation of Nurturance: Absence of attention, affection, warmth, or companionship. B. Deprivation of Empathy: Absence of understanding, listening, self disclosure, or mutual sharing or feelings from others. C. Deprivation of Protection: Absence of strength, direction, or guidance from others. Enmeshment (EM) Excessive emotional involvement and

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288 closeness with one or more significant others (often parents), at the expense of full individuation or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. May also include feelings of being smothered by, or fused with, others or insuffic ient individual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme Entitlement (ET) The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interactions. Often involves insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on superiority (being among the most successful, famous, wealthy) in order to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward, or domination of othe point of view, or controlling the behavior of without

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289 feelings Insufficient Self Control (IS) Pervasive difficulty or refusal to exer cise sufficient self control and frustration tolerance impulses. In its milder form, patient presents with an exaggerated emphasis on discomfort avoidance: avoi ding pain, conflict, confrontation, responsibility, or overexertion at the expense of personal fulfillment, commitment, or integrity. Mistrust/Abuse (MA) The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually involves the perception that the harm is intentional or the result of unjustified and extreme negligence. May include the sense that one always ends up I do very much resen t how things transpired in my me to really feel safe around people and trust them to get close with them. To connect with them. I have blanket trust issues period. But maybe that is why I am not marrie what. Because my dad is a pretty charming guy with the same kind of situa tion my mother was in My mo ther has a bit of an irrational temper. Like she will just start and go at it an d it is a bit much. My mother would call him all kinds of names. She would talk about his mother and he woul d n ever

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290 push back on that. Subjugation (SB) Excessive surrendering of control to others because one feels coerced usually to avoid anger, reta liation or abandonment. The two major forms of subjugation are: A. Subjugation of Needs: Suppression of B. Subjugation of Emotions: Suppression of emotional expression, especially anger. Usually involves the desires, opinions, and feelings are not valid or important to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Generally leads to a build up of anger, manifested in maladap tive symptoms (e.g., passive aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal I was a incredibly compliant kid. My mother 8:30 or 9:00 and I would be in bed by 8:30 or 9:00. homework was done. I was 14 or 15 until I realized that I could watch TV until about half an hour before she got home and then turn it off and the TV wou think to check to see if the TV had been on. So I was really compliant. stuff so again being the compliant person I would just like bring a book or I would pray they had some magazines and I would read magazines. I would just sit there and read a magazine and watch TV. And I kind of learned that my mother is not a mind reader and so I would have to express myself. The orever so I had t o speak up for myself. on. He still drank quite a bit. And I would just go

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291 and we would do stuff and I was expected to try and shake him down for stuff anyway, so I had to go and I had to kind of make an effort to at least try because I knew when I got home that my mother a class trip to go on? Did your daddy give you some money? Yeah I really felt obliged to go. I yed visiting my father. It was like j u st get this over with. and I shrug and try to focus on something else. And that is a pretty unsa tisfactor y way to be. I will find myself grousing to myself about some issue where I should have spoken up or something and/or when taken it on and it is not really something I can do anything about and I will be like oh my gosh I will be thinking about it over s ome cookies and so I think sometimes thank God I ly have a problem. I feel comfort. Oh food feels good in your stomach and it tastes good and it takes you out of whatever painful thing you were thinking abou t especially if you have to make or go get it or wait for someone to bring it to you.

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292 Social Isolation/Alienation (SI) The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community. I may not have been overweight when I look at it now. I went to a predominately white school. And I developed early and secondly I have very different characteristics. My butt was rounder my thighs were bigger I looked probably more womanly then the oth er 13 year old girls. I think also my experience with being usually the only minority person or African American in a lot of school settin gs was very isolating. Or something would come up to remind me of my outsider status and that would upset me very much because there was nothing I cou ld really do about it. Self Sacrifice (SS) Excessive focus on voluntarily meeting the needs of others in daily situations, at the common reasons are: to prevent causing pain to others; to avoid guilt from feeling selfish; or to maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pain of others. needs are not being adequately met and to resentment of those who are taken care of. (overlaps with sense of co dependency) Emotional inhibition (EI) The excessive inhibition of spontaneous action, Q: Would you say you are a stress eater? A: Yes.

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293 feeling or communication usually to avoid disapproval by others, feelings of shame, or losing common areas of inhibition involve: (a) inhibition of anger & aggression, (b) inhibition of positive impulses (e.g. joy, affection, sexual excitement, play); (c) difficulty expressing vulnerability or communicating fre ely about emphasis on rationality while disregarding emotions. And whenever I have stressful or hurtful time I tend to overeat and I tend to eat quite a bit of crap. couple dozen cookies and eat them. So I guess I try to be sensible about it and maybe care about my looks it makes it e asier to be overweight. I feel comforted. Oh food feels good in your stomach and it tastes great and it takes you out of whatever painful thing you were thinking about especially if you have to make or go get or wait for someo ne to bring it to you. I remember being home alone at the age of 7 and feeling profound ly alone. We had some cereal and little snack packs of chips and soda and some snack cakes. I ate just about all of Twinkies and I must have drank three or four so das So I remember that it was one of the first instances

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294 where I did connect food with an emotion. And you know it was loneliness and that was my solution, just eat. When I am frust rated, angry or sad I eat. There was a period in junior high where the re was just a lot of racial incidents that kept happening on the school bus and I would get home and be pretty upset about it and I would eat. I would have a full meal. If there were leftovers I would eat those and then I would look for something else an d then I would eat dinner to try and cover up for the other I guess I just cook up a couple dozen cookies. Q: And eat them? A: Yeah Failure to achieve (FA) The belief that one has failed, will inevitably fail, or is fundamentally inadequate relati ve to career, sports, etc). Often involves beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc. like of agreement with myself. Unrelenting standards/Hyper criticalness (US) The underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criti cism. Typically results in feelings or pressure or difficulty slowing down; and in I think I feel like it is incredibly superficial to do that. I would like to think that I am not a judgmental pe rson but I see somebody come in with French tips I make a snap judgment. And the snap judgment I make on them is not one I want

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295 hypercriticalness toward oneself and others. Most involve significant impairment in: pleasure, relaxation, health, self esteem, sense of accomplishment, or satisfying rela tionships. Unrelenting standards typically present as (a) perfectionism, inordinate attention to detail, or performance is relative to the norm; (b) rigid including unrealis tically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that more can be accomplished. peop le to making about me. I know how people are suppose to be and I am very a tuned to that. I like, order, I like priority, I like decency. The fact that it has not always been a value of the people around me is painful because I feel like an outlier. And sometimes I Vulnerabil ity to harm (VH) Exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the following: (a) medical catastrophe: e.g., heart attacks, AIDS; (b) emotional catastrophes e.g. going crazy (c) external catastrophes; e.g. elevators collapsing, victimized by criminals, airplanes crashes, earthquakes. Approval seeking/Recognition seeking (AS) Excessive emphasis on gaining approval, recognition, or attention from other people, or fitting in, at the expense of developing a secure dependent primarily on the reactions of others I de veloped early and secondly I had very different characteristics. But I always thought that if I lost weight I would look like this. So that became kind of a spiral of trying to be skinnier. If I looked like this I would fit in better.

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296 Sometimes includes an overemphasis on status, appearance, socia l acceptance, money, or achievement as mean of gaining approval, admiration, or attention (not primarily for power or control). Frequently results in major life decisions that are inauthentic or unsatisfying; or in hypersensitivity to rejection. Negativity/Pessi mism (NP) A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc) while minimizing or neglecting the posi tive or optimistic aspects. Usually includes an exaggerated expectation in a wide range of work, financial, or interpersonal situations that things will ultimately fall apart. Usually Punitiveness (PU) The belief that people should be harshly punis hed for mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with those people ( and self) who do not meet includes difficulty forgiving mistakes in because of a reluctance to consider e xtenuating circumstances, allow for human imperfection or empathize with f eelings. I decided I was sick of all this and it is easy to just not deal with my father at all. At 19 I decided I to. I never cal led him or saw h im after that. (Father).

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297 Appendix K Coding Donna Bulimia Nervosa Category Definition Participant Statement Abandonment/Instability (AB) The perceived instability or unreliability of those available for support and connectio n. Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable, unreliable, or erratically present; because the y will die imminently; or because they will abandon the patient in favor of someone better. He was too obsessed with their failing marriage so divorced and then he knew we were the only family he had l really have a lot of time to think about us kids because he was trying t o hold on to the marriage. My dad sent me back to my mom after four months. there I was only successful in my parents home for a month before I actually got caught at school smoking pot and they did not press charges but my mom put me in t he teen crisis shelter My mother said do whatever you want. You think you are a grown up you do what y ou want and just stay there. And then 6 hours later the cops came to pick me up because she had changed her mind. So I went to juvey and they called my mother and said

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298 an offense. And my mom said I am not coming to get her. They said then we consider that abandonment and I was turned over to chi ld protective services. It depended on how many cases of alcohol they had at the time. My father has the standing record today for being pretty stable. My m other has the record for being somewhat stable for prolonged periods of time. I wanted her attention more than everyone else because everyone else will just give it to me and she made me beg for it. Defectiveness/Shame (DS) The feeling that one is defec tive, bad, unwanted, inferior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involved hypersensitivity to criticism, rejection, and blame; self consciousness, comparisons, and insecurity around othe rs; or a sense of shame may be private (e.g. selfishness, angry impulses, unacceptable sexual desires) or public (undesirable physical appearance, social awkwardness). I have not had a day go by that I have not rejected some part of my body. started eating potato chips and then threw them up. any hope for me. There is no reason to try and help myself because I will always b e just this screwed up. I have lots of obsessive compulsive and se lf centered behaviors in my

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299 I don So in my recovery what I have been trying to address for a long time is to stop hating myself so much. I have to practice at being somebody that I want to be and I think it was 6 months ago that I finally started to feel really successful at this practicing being someone that I wanted to be thing and I started to feel a lot of these feelings of esteem. Recovery I used to loath myself for now I see as more of a quirky you know traits I still need to work on to be of better se rvice to other people. Recovery Yes and I have always hated myself for that and then recently it is just you know what I know what I think and that is okay and I will just have to learn more politeness. I have already been learning about politeness and this is actually okay that I can incorporate this into my confidence and my idea of mys elf. Recovery

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300 I started out with this hatred for myself and n ow it has just changed. Recovery Dependence/Incompetence (DI) everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). Often presents as helplessness. Emotional Deprivation (ED) degree of emotional support will not be adequately met by others. The three major forms of deprivation are: A. deprivation of Nurturance: Absence of attention, affection, warmth, or companionship. B. Deprivation of Empathy: Absence of understanding, listening, self disclosure, or mutual sharing or feelings from others. C. Deprivation of Protection: Absence of strength, direction, or guidance from others. She did not have the ability to talk things out which is what I really would have benefited from. which is what I really would have benefited from. You or things that make us feel good then just eating and talk about her problems. She would just try to co ntrol. And when she me she would ignore me. She would not speak to me. And I would beg for her attention and be all up in her face and she wou ld completely ignore me. Enmeshment (EM) Excessive emotional involvement and closeness with one or more significant others

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301 (often parents), at the expense of full individuation or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other May also include feelings of being smothered by, or fused with, others or insufficient individual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme cases questioning Entitlement (ET) The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interactions. Often involves insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on superiority (being among the most successful, famous, wealthy) in order to achieve power or control (not primarily for attention or a pproval). Sometimes includes excessive competitiveness toward, or domination of point of view, or controlling the behavior of without or

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302 feelings Insufficient Self Control (IS) Pervasive difficulty or refusal to exercise sufficient self control and frustration tolerance impulses. In its mil der form, patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion at the expense of personal fulfillment, commitment, or integrity. as going on any other way and I started binging and purging Well when I made the decision to use it was like a compulsion. It was like I wanted to use a four letter word but screw it. You know. It is kind of a familiar thing in my stream of consciousn ess where just going to do it. is one of the things I say to myself. I really love to do it and I find it difficult to control myself at times and so I think it is bo th things. I would like to tell myself I was eating too little and my body revolted and I have to put more food in but it is also that I have less control over m yself as I would like. Q: What do you think you were gaining from binging and purging/ A: Control of my feelings, avoiding reality, not taking personal responsibility for my life, myself, my feelings, everything. Mistrust/Abuse (MA) The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually inv olves the perception that the harm is intentional or the result of unjustified and extreme negligence. May Especially me. And she would po rtion control my food because she believed I show ed signs of over eating. M y dad found out that my mom had been beating

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303 include the sense that one always ends up being me up when I was two. step yet and it messed me up in the head for a while Liar is the word the comes to mind. I think she can twist and change the truth in her own mind. She is not an honest woman. I would trust her with my physical well being to a point. Because if I go on a trip with her and it is just her and she is drinking an want to be in t hat type of situation like why would you want to reas on with a crazy person. I was 13 by then. My stepfather started hitting my younger sister and I still didn started hitting me that is when I started to use. She was lying. She never told me this and never will but I know she was lying to me. Subjugation (SB) Excessive surrendering of control to others because one feels coerced usually t o avoid anger, retaliation or abandonment. The two major forms of subjugation are: My right to control myself had been removed. Q: By yo ur stepfather? A: Yes. Every time I did something wrong they would take

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304 A. Subjugation of Needs: Suppression of B. Subjugation of Emotions: Suppression of emotional expression, especially anger. U desires, opinions, and feelings are not valid or important to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Generally leads to a build up of anger, ma nifested in maladaptive symptoms (e.g., passive aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal my life away. They would take the little jar that is me and turn it upside down in an effort to control me and I would work to feel nothing. Their own expression of themselves. My right to control m yself had been removed. He was that type of person goes and tries to rob that per son of their control. Q: So he robbed you of y our control? A: Yes. Social Isolation/Alienation (SI) The feeling that o ne is isolated from the rest of the world, different from other people, and/or not part of any group or community. Self Sacrifice (SS) Excessive focus on voluntarily meeting the needs of others in daily situations, at the on. The most common reasons are: to prevent causing pain to others; to avoid guilt from feeling selfish; or to maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pain of others. Sometimes leads to a se being adequately met and to resentment of those who are taken care of. (overlaps with

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305 sense of co dependency) Emotional inhibition (EI) The excessive inhibition of spontaneous action, feeling or communication usually t o avoid disapproval by others, feelings of shame, or common areas of inhibition involve: (a) inhibition of anger & aggression, (b) inhibition of positive impulses (e.g. joy, affection, sexual excitement, play); (c) difficulty expressing vulnerability or communicating freely about emphasis on rationality while disregarding emotions. When you parents are kicking you out it is like this resignation would be a lot of how I would feel. I would get this numb. I would describe kind of like PTSD type respons e. I had no feeling. Then I started cutting myself a little bit and then I told on myself for cutting The underlying feeling I was trying the suppress was having to d eal with my body and accept ing my body and myself. Failure to achieve (FA) The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to career, sports, etc). Often involves beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc. Unrelenting standards/Hyper criticalness (US) The underlying belief that one must strive to meet very high internalized standards of behavior a nd performance, usually to avoid criticism. Typically results in feelings or pressure or difficulty slowing down; and in hypercriticalness toward oneself and others. Most involve significant impairment in: pleasure, relaxation, health, self esteem, sense of accomplishment, or satisfying relationships. I have lots of obsessive compulsive and self centere d behaviors in my life. So I would eat something and then realize it was a mistake and I would have to ma ke myself throw it up. Yes I would eat more than the 1350 and that rigid black and white thinking I would not think that

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306 Unrelenting standards typically present as (a) perfectionism, inordinate attention to detail, or performance is relative to the norm; (b) rigid many areas of life, including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that more can be accomplished. 1400 was a successful diet day. Q: SO if you went over 1350 what would happen. A: I w ould throw up. Vulnerability to harm (VH) Exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the following: (a) medical catastro phe: e.g., heart attacks, AIDS; (b) emotional catastrophes e.g., going crazy (c) external catastrophes; e.g. elevators collapsing, victimized by criminals, airplanes crashes, earthquakes. Approval seeking/Recognition seeking (AS) Excessive emphasis on ga ining approval, recognition, or attention from other people, or fitting in, at the expense of developing a secure dependent primarily on the reactions of others Sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievement as mean of gaining approval, I wanted her attention more than everyone else because everyone else will just give it to me an d she made me beg for it. My mom was controlling my food and I think I was trying to be in denial. I would goad her at times to tell me I was the right size. And I would find opportunities to ask her to tell me

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307 admiration, or attention (not primarily for power or control). Frequently results in major life decisions that are inauthenti c or unsatisfying; or in hypersensitivity to rejection. tha t I was the right size. I think that people like me if I don this then I will be loved, if I do that I will be okay. If I do this then I wil l be acceptable in society. Negativity/Pessimism (NP) A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong etc) while minimizing or neglecting the positive or optimistic aspects. Usually includes an exaggerated expectation in a wide range of work, financial, or interpersonal situations that things will ultimately fall apart. Usually Punitiveness (PU) The belief that people should be harshly punished for mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with those people (including oneself) who do Usually includes difficulty forg iving mistakes in oneself or others, because of a reluctance to consider extenuating circumstances, allow for human imperfection or empathize with feelings. I never thought my mother was giving me her approval so I rejected her as a punishment and as a way of dealing with the rejecti on of myself from her.

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308 Appendix L Coding Jade Bulimia Nervosa Category Definition Participant Statement Abandonment/Instability (AB) The perceived instability or unreliability of those available for support and con nection. Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable, unreliable, or erratically present; becau se they will die imminently; or because they will abandon the patient in favor of someone better. My parents said we would move back to Mexico after I graduated. Once we did they decided not to stay and so I was left alone. For those 9 months I was pr ett y much living on my own. I was in Mexico by myself so I was dealing with how to cope with it any other way. I mean I l iterally grew up on my own. Defectiveness/Shame (DS) The feeling that one is def ective, bad, unwanted, inferior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involved hypersensitivity to criticism, rejection, and blame; self consciousness, comparisons, and insecurity around ot hers; or a sense of shame may be private (e.g. selfishness, angry impulses, unacceptable sexual desires) or And so growing up it was a lot you don far as being Hispanic or being American. I was like not good enough for either one. I felt that way anyway The older I got the more my mom pointed out that I was getting too involved in the American life style and then that I was denying my roots. And Hispanic th e less successful I was. I was not a very popular kid. Not only that, but

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309 public (undesirable physical appearance, social awkwardness). when I was growing up, I was compared to a petite pers on. Like really, really tiny. So the comparisons were always that I was a l ittle heavier than her. And somewhere in my mind I thought she was always be tter than me in that way I feel so inadequate and I still wake up some days and think you have done no thing with your life You are not successful and that is why no one wants you. You are this, and you are ugly. that. I did so good. And then there is like a high that you get. Because you relie ved but it is like well I just got rid of something that was not suppose to be there. And then it lasts for a good 5 or 10 minutes un til the guilt comes in. And if there was any stress going on in my mind I think that it has to do with concerns like bein g able to control the thoughts that go in. It is like you wake up with problems that are going around the house or feelings of inadequacy that I am not good enough so I am just go ing to torture myself.

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310 going to make you fat. So not only do I not feel good this is only going to make you fat. But at the same time I have always kept my body in shape I would still hide it under big clothes. So in my brain it was like, wel l I am still in really good shape accepted even w hen my body was little. There was always a lot of guilt afterward becau se I knew it was wrong. I felt very shameful. I guess expectations of me being the excellent daughter has always been the re and sometimes it is just like you know what I am just human. And you know what it is just like sometimes I know it is like I told my mom you thinking that I have it all put struggling with lots of t hings and I need for you to understand that I am just as human as anybody else. I am struggling with a lot of things, and I need for you to understand that I am just as h uman as anybody else. Recovery

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311 Dependence/Incompetence (DI) Belief that one is unab everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). Often presents as helplessness. An d I had no clue and again I had no control ov er anything whatsoever I feared decision making and that even applies now. I am still struggling with that, and giving in to to go by what ev erybody else to ld me. Emotional Deprivation (ED) degree of emotional support will not be adequately met by others. The three major forms of deprivation are: A. deprivation of Nurturance: Absence of attention, affection, wa rmth, or companionship. B. Deprivation of Empathy: Absence of understanding, listening, self disclosure, or mutual sharing or feelings from others. C. Deprivation of Protection: Absence of strength, direction, or guidance from others. My father is very distant. He is a caring person but world. So it is lik e, it is about him. emotions. He just goes through the process of living I did wish that I had so meone I could rely on like my dad to protect me or car e for me, or whatever. Enmeshment (EM) Excessive emotional involvement and closeness with one or more significant others (often parents), at the expense of full individuation or normal social developm ent. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. May also include feelings of being smothered My mom suffers from an eating disorder, anorexia, so through her process I was like on me. Fear, over invo lvement in others lives and I would say my moms would be it, no life of my own. I felt it was my responsibilit y to make her feel

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312 by, or fused with, others or insufficient individual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme cases questioning better. Because I still take blame for, well not blame but I sti ll try fix my mother. She is such a caring person yet at the same time she is so fragile t hat I want to fix her. Entitlement (ET) The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interactions. Often invol ves insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on superiority (being among the most successful, famous, wealthy) in o rder to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward, or domination of point of view, or controlling the behavior of others in line wit without feelings Insufficient Self Control (IS) Pervasive difficulty or refusal to exercise sufficient self control and frustration tolerance

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313 th impulses. In its milder form, patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion at the expense of personal fulfillmen t, commitment, or integrity. Mistrust/Abuse (MA) The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually involves the perception that the harm is intentional or the result of unjustified and extreme ne gligence. May include the sense that one always ends up being My parents always told me we would go back to Mexico and so I thought in my mind that I always wanted to go back and it seeme d like a lot of broken promises because we never did But yet at the same time she has this powerful character and personality that is manipulative at the same time that if you get too close to her she will make your life miserable. So it is like how do I approach my mother so that I affect me so much that I become mi serable in the process. anybody. Not even my mom at that point anymore. So I am not g oing there with my dad. I c ask him for help.

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314 Subjugation (SB) Excessive surrendering of control to others because one feels coerced usually to avoid anger, retaliation or abandonment. The two major forms of subjugation are: A. Subjugation o f Needs: Suppression of B. Subjugation of Emotions: Suppression of emotional expression, especially anger. desires, opinions, and feelings are not valid or import ant to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Generally leads to a build up of anger, manifested in maladaptive symptoms (e.g., passive aggressive behavior, uncontrolled outbursts of temper psychosomatic symptoms, withdrawal Social Isolation/Alienation (SI) The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community. So it w as ea sy to hide and lie about it. the language, you have to learn a new language, you you never have friends, your pare nts work all the time. k to anyone because y the language. Self Sacrifice (SS) Excessive focus on voluntarily meeting the So my dad was working all the time and so it all

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315 needs of others in daily situations, at the common reasons are: to prevent causing pain to others ; to avoid guilt from feeling selfish; or to maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pain of others. Sometimes being adequately met and to resent ment of those who are taken care of. (overlaps with sense of co dependency) came down to me. I was forced to grow up real quick when I was little I had to protect her, I had to make her feel good, I had to keep her happy. And for a kid that is kind of hard. My coping mechanism is stop feeling sorry for yourself and see what you can do for someone else that feels wo rse than you do. Emotional inhibition (EI) The excessive inhibition of spontaneous action feeling or communication usually to avoid disapproval by others, feelings of shame, or common areas of inhibition involve: (a) inhibition of anger & aggression, (b) inhibition of positive impulses (e.g. joy, affection, sexual excitement, play); (c) difficulty expressing vulnerability or communicating freely about emphasis on rationality while disregarding emotions. It was one of those things you do to try and comp ensate the feeling the food, and you over eat so much in such a short period of time and then the guilt that I over ate too much and then the fact that I when I am little you have to go get rid of it right a way. Well I was really stressed and I would eat, and eat, and eat and then just get rid of it again. There was a hat I was going to do. Like this eating is going to make me feel better, and um, it was just a coping m echanism because I was so stressed out that I would eat and then just keep eating and eating and eating and by the time you

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316 realize it you have eaten so much and then you do feel good. So I was in Mexico by myself so I was dealing with being lonely. I wa coping mechanism came in that way. I just cant control anything, so I will eat and purge and I will stay skinny. While your eating it ju st kind of relaxes you Failu re to achieve (FA) The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to career, sports, etc). Often involves beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc. still not there for my mother the way I wish I could. A lot of fear always making the wrong decisio ns for a lot of things But again that little vo ice will come out and says no you Unrelenting standards/Hyper criticalness (US) The underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criticism. Typically results i n feelings or pressure or difficulty slowing down; and in hypercriticalness toward oneself and others. Most involve significant impairment in: pleasure, relaxation, health, self esteem, sense I have been a perfectionist. I have always been an over achiever, I always want to accomplish mor e than I think I can. Sometime I feel l i ke I am not doing enough. It is like if nobody likes me, then I am going to

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317 of accomplishment, or satisfying relationships. Unrelenting st andards typically present as (a) perfectionism, inordinate attention to detail, or performance is relative to the norm; (b) rigid including unrealistically high moral, ethica l, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that more can be accomplished. torture myself s o that I can be skinny I think again I always try to keep the faith that I was the perfect kid who never did anything wrong. And as an adult, I still want to ke ep the thing that I never make a mistake. The perfectionism is like oh I am I still here the mom voices and the dad voices because my dad always told me I was super smart. There is a little voice somewhere in the back of my head that is ju st an over achiever and it is like you are not going to get stuck in that. I have been trying to present as this little robot s perfect and I am not. Vulnerability to harm (VH) Exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the following: (a) medical catastrophe: e.g., heart attacks, AIDS; (b) emotional catastrophes e.g., going crazy (c) external catastrophes; e.g. elevators collapsing, victimized by crimin als, airplanes crashes, earthquakes. Approval Excessive emphasis on gaining approval,

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318 seeking/Recognition seeking (AS) recognition, or attention from other people, or fitting in, at the expense of developing a secure of esteem is dependent primarily on the reactions of others Sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievement as mean of gaining approval, admiration, or attent ion (not primarily for power or control). Frequently results in major life decisions that are inauthentic or unsatisfying; or in hypersensitivity to rejection. stay little that will be the way to g et accepted. I immediately got noti ced when I lost the weight. And in my mind again as I got older I was like well, if I can stay this little everyone is going to like me more. I still do struggle with fear an d trying to please others There was so muc h of a desire to be accepted and I felt that by losing a little bit of weight that I would be accepted and then it becomes sort of like a circle. Because people say you look good, so then you you want to do it but you do it more, and more, and more and it becomes a pattern. I am only accepted when I am little you have to go get rid of that food right awa y. It was always in the back of my mind that I had to ould make me accepted. N egativity/Pessimism (NP) A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment,

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319 unsolved problems, potential mistakes, betrayal, things that could go wrong, etc) while minimizing or negl ecting the positive or optimistic aspects. Usually includes an exaggerated expectation in a wide range of work, financial, or interpersonal situations that things will ultimately fall apart. Usually Punitiveness (PU) The belief that people should b e harshly punished for mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with those people (including oneself) who do Usually includes difficulty forgiving mistakes in oneself or ot hers, because of a reluctance to consider extenuating circumstances, allow for human imperfection or empathize with feelings.

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320 Appendix M Coding Carla Bulimia Nervosa Category Definition Participant Statement Abandonment/Instability (AB) Th e perceived instability or unreliability of those available for support and connection. Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emo tionally unstable and unpredictable, unreliable, or erratically present; because they will die imminently; or because they will abandon the patient in favor of someone better. Then my mother moved to Florida and actually left me with my step dad until I g r aduated from high school I was still dealing with some things from my childhood and the feeling of my mother abandoning me and stuff. Description of mother: Unreli able, unpredictable, abandoned. Defectiveness/Shame (DS) The feeling that one is defe ctive, bad, unwanted, inferior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involved hypersensitivity to criticism, rejection, and blame; self consciousness, comparisons, and insecurity around oth ers; or a sense of shame may be private (e.g. selfishness, angry S o then I feel unattractive. When I th ink about it I feel guilty.

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321 impulses, unacceptable sexual desires) or public (undesirable physical appearance, social awkwardness). Dependence/Incompetence (DI) everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judg ment, tackle new tasks, make good decisions). Often presents as helplessness. Emotional Deprivation (ED) degree of emotional support will not be adequately met by others. The three major forms of deprivation a re: A. deprivation of Nurturance: Absence of attention, affection, warmth, or companionship. B. Deprivation of Empathy: Absence of understanding, listening, self disclosure, or mutual sharing or feelings from others. C. Deprivation of Protection: Abs ence of strength, direction, or guidance from others. were kind of three generations and I really think that had a lot to do with my mother inability to a parent a good pa rent as well. was more like a person who kept the lights on. He definitely displayed a lack of warmth and affection. (father) Definitely la ck of warmth and affection. (mother) hurt, lack of affection lack of understan ding, lack of guidance. I notice that even when I got into school she says that she is proud of me and I think that she is not proud of me but more like my daughter is a graduate student type thing not really me. And I

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322 would tell her l ike real things and she is not even would be saying something really intense and she would be like Yeah I order these new whatever that I saw in a magazine and I hope they work out. Enmeshment (EM) Exces sive emotional involvement and closeness with one or more significant others (often parents), at the expense of full individuation or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be h appy without the constant support of the other. May also include feelings of being smothered by, or fused with, others or insufficient individual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme ca ses questioning I have been the parent in the relationship for a lot of years. And I have always, out of a sense of parent. She is ju st a DNA dono r is how I look at it. But we bailed her out and moved her in with us. Kind of that tough love thing and I kept thinking I For years I played the mediator between the two of them. Entitlement (ET) The belief tha t one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interactions. Often involves insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on The poi nt when I was ready to leave him I said, look I opened your business store, I struggled with two electric bills, two phone bills, I mean I did everything. I mean I managed the store and the household and I raised you daughter. I said I gave you 10 years now I am going to school. it is going to be harder for me to go to school if I leave you so like it or not you are going to be stuck with me u ntil

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323 superiority (being among the most successful, famous, wealthy) in order to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward, or domination of point of view, or controlling the behavior of without feelings I finish school. Insufficient Self Control (IS) Pervasive difficulty or refusal to exercise sufficient sel f control and frustration tolerance impulses. In its milder form, patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict confrontation, responsibility, or overexertion at the expense of personal fulfillment, commitment, or integrity. Mistrust/Abuse (MA) The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually involves t he perception that the harm is intentional or the result of unjustified and extreme negligence. May include the sense that one always ends up being I was sexually abused and I had some co ntrol issues there and I think I put on weight to keep men f rom wanting to look at me. It was multiple people, primarily an older step brother, cousin, my step sister did a couple of things.

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324 She calls her father every once in a while but she talk to me because it is all my fault. It still hurts if I think about it and I still get angry sometimes when I think about it. It was safe there none of the other kids were there and nobody would hurt me there (139 140) I have been through so much tha t it is fairly easy for me to not rely on an ybody in any situation. So I never know if she was telling the truth or not Subjugation (SB) Excessive surrendering of control to others because one feels coerced usually to avoid anger, retaliation or aband onment. The two major forms of subjugation are: A. Subjugation of Needs: Suppression of B. Subjugation of Emotions: Suppression of emotional expression, especially anger. Usually involves the perception that desires, opinions, and feelings are not valid or important to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Generally leads to a build up of anger, manifested in maladaptive symptoms (e .g., passive

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325 aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal Social Isolation/Alienation (SI) The feeling that one is isolated from the rest of the world, different fro m other people, and/or not part of any group or community. Self Sacrifice (SS) Excessive focus on voluntarily meeting the needs of others in daily situations, at the common reasons are: to prevent causing pai n to others; to avoid guilt from feeling selfish; or to maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pain of others. Sometimes being adequately met an d to resentment of those who are taken care of. (overlaps with sense of co dependency) She was out there a couple of years and then she called and said I want to come home and go back to school. She was engaged so we said that is fine and so we got her, her fianc and her little dog which I ended up being stuck with. I said you can come but they were both l azy, sloppy, and dirty. I am not going to leave you until your daughter graduates from high school because I know what t hat will do to a kid. And I am very responsible when I make a commitment and really just for her I felt like I had made that commitment and I owed her that because it is not her faul t who her parents were I feel like I have sacrifi ced my whole life for other people. He told me he wanted to kill himself and he told me how he was going to do it and it freaked me out and

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326 so I begged him I will come see you just promise a leave of ab sence from both of my jobs and I drove home and told my step dad. ay and not do anything. Emotional inhibition (EI) The excessive inhibition of spontaneous action, feeling or communication usually to avoid disapproval by others, f eelings of shame, or common areas of inhibition involve: (a) inhibition of anger & aggression, (b) inhibition of positive impulses (e.g. joy, affection, sexual excitement, play); (c) difficulty expressing vulner ability or communicating freely about emphasis on rationality while disregarding emotions. It is just that I do Are you kidding me. We are barely making ends mee t and I am a student. How dare you complain about taking care of my grandmother and then tell to her but it is what I was thinking. strong I really sometimes think that maybe we will have a dish of ice cream at night or we will bond over food, popcorn, and a movie instead of actual ly physically bonding. Q: Are you replacing sex with food? A: I think sometimes I am. Failure to achieve (FA) The belief that one has failed, will inevitably fail, or is fundam entally inadequate relative to career, sports, etc). Often involves beliefs that I feel guilty because looking b ack I have learned some things and I think there were so many things I could have done better with her.

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327 one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc. Three weeks after our wedding I thought I might have made the bigge st mistake of my life. Unrelenting standards/Hyper criticalness (US) The underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criticism. Typically results in feelings or pressure or difficulty slowing down; and in hypercriticalness toward oneself and others. Most involve significant impairment in: pleasure, relaxation, health, self esteem, sense of accomplishment, or satisfying relationships. Unrelenting standards typically present as (a) perfectionism, inordinate attention to detail, or an underestimate of how go performance is relative to the norm; (b) rigid including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that more can be accomp lished. I am too much of a perfectionist. I expected too much from him as far as how I think our relationship should be and how I think the house should be. I ha ve real control issues Once I started to lose weight it was like an addictive quality that I wan ted to lose more weight. I went through a state where even if I ate a little bit I of it. Vulnerability to harm (VH) Exaggerated fear that i mminent catastrophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the following: (a) medical catastrophe: e.g., heart attacks, AIDS; (b) emotional catastrophes e.g., going crazy (c) external catastrophes; e.g. elevators collapsing, Just feeling attractive was kind of scary. I wanted it but I was afraid of it du e to the sexual abuse.

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328 victimized by criminals, airplanes crashes, earthquakes. Approval seeking/Recognition seeking (AS) Excessive emphasis on ga ining approval, recognition, or attention from other people, or fitting in, at the expense of developing a secure dependent primarily on the reactions of others Sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievement as mean of gaining approval, admiration, or attention (not primarily for power or control). Frequently results in major life decisions that are inauthenti c or unsatisfying; or in hypersensitivity to rejection. I got real thin and the b oys started noticing me. Negativity/Pessimism (NP) A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentme nt, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc) while minimizing or neglecting the positive or optimistic aspects. Usually includes an exaggerated expectation in a wide range of work, financial, or interpersonal sit uations that things will ultimately fall apart. Usually Punitiveness (PU) The belief that people should be harshly punished for mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient

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329 with those people (including oneself) who do Usually includes difficulty forgiving mistakes in oneself or others, because of a reluctance to consider extenuating circumstances, allow for human imperfection or empathize with feelings.

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330 Appendix N Codin g Jillian Anorexia Nervosa Category Definition Participant Statement Abandonment/Instability (AB) The perceived instability or unreliability of those available for support and connection. Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable, unreliable, or erratically present; because they will die imminently; or because they will abandon the pat ient in favor of someone better. Defectiveness/Shame (DS) The feeling that one is defective, bad, unwanted, inferior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involved hypersensitivity to cri ticism, rejection, and blame; self consciousness, comparisons, and insecurity around others; or a sense of shame may be private (e.g. selfishness, angry impulses, unacceptable sexual desires) or I despise myself. A color that comes to mind is very black very angry black. I hate the way I look because of the way I have put on the weight. I find it very hard to s ay nice things about myself. I didn f elt fat and unacceptable. Old habits die hard and I was into a lot of stuff that I

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331 public (undesir able physical appearance, social awkwardness). wish I had nev er gotten involved in. I find it very hard to say nic e things about myself. Dependence/Incompetence (DI) Beli everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). Often presents as helplessness. making. It affects how I feel about myself a lot of it is things that have been said by him. I fear decision my partner to make all the import ant decisions. It is kind of weird because I know I can make my how. So I usually make a decision but before I actually go through with it I am always asking is this okay should I do this. I am not reall y su re of myself I guess. I knew nothing about moving until the day I was getting released. My fianc told me on the telephone that he and dad had a chat. I was freaking out and ha d a panic attack in the hospital It is weird because I know I can make my own decisions but I a

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332 Emotional Deprivation (ED) degree of emotional support will not be adequately met by others. The three major forms of deprivation are: A. deprivation of Nurturance: Absence of attention, affection, warmth, or companionship. B. Deprivation of Empathy: Absence of understanding, listening, self disclosure, or mutual sharing or feelings from others. C. Deprivation of Protection: Absence of strength, di rection, or guidance from others. A lack of warmth, and lack of understanding (father). Enmeshment (EM) Excessive emotional involvement and closeness with one or more significant others (often parents), at the expense of full individuation or normal so cial development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. May also include feelings of being smothered by, or fused with, others or insufficient individ ual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme cases questioning Mom and I have a really good relationship. We talk every day. I st ill share everything with her. ow what happened if anything but it did start of slew of mistrust between my parents and I would consistently hear from my mom what my dad was doing and consistently hearing from my dad what my mom was doing and it was constantly back and forth. I was lik e the person that could hear e talking to anybody. I have a lack of separate identity. With him, he listened to country music so I list ened to country music.

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333 k I have changed the lacking separate identity. I am working on it. I kind of lose it and then I get stuck into it and then I start feeling miserable, and I am like why am I feeling and I figure out oh I am acting like what the other person is acting lik e and I gotta get out of there. Entitlement (ET) The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interactions. Often involves insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on superiority (being among the most successful, famous, wealthy) in order to achieve pow er or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward, or domination of point of view, or controlling the behavior of without feelings Insufficient Self Control (IS) Pervasive difficulty or refusal to exercise sufficient self control and frustration tolerance A couple of instances I have dissociated during the day and ended up in places where I have no idea how I got there.

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334 the excessive expre impulses. In its milder form, patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion at the expense of personal fulfillment, commitment, or integrity. And it is kind of out of my control, something I it where I will follow my little routine, whatever. And some days I don And I start, gotta do this, and immediately it starts and it is right there and th ere is no stopping me. Mistrust/Abuse (MA) The expectation that others will hurt, abuse, humilia te, cheat, lie, manipulate, or take advantage. Usually involves the perception that the harm is intentional or the result of unjustified and extreme negligence. May include the sense that one always ends up being e short The time I spend with him now is all in prote cted settings My first boyfriend was my first kiss, my first a lot of things and he kind of took advantage of my I was nave I think he took advantage o f me in a lot of ways. The way he was treating me I did not feel was matching what he was saying. get a what you should do answer. Subjugation (SB) Excessive surrendering of cont rol to others because one feels coerced usually to avoid anger, retaliation or abandonment. The two major forms of subjugation are:

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335 A. Subjugation of Needs: Suppression of B. Subjugation of Emotions: Suppre ssion of emotional expression, especially anger. desires, opinions, and feelings are not valid or important to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling t rapped. Generally leads to a build up of anger, manifested in maladaptive symptoms (e.g., passive aggressive behavior, uncontrolled outbursts of temper, psychosomatic symptoms, withdrawal Social Isolation/Ali enation (SI) The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community. M y dad, different from other people I think both and not part of a group or community, my dad Maybe differen understand me, neither do I. I was not very social people because I always felt fat and unacceptable. out or do things. I like to h ide and am very uncomfortable in the way my body looks right now. Self Sacrifice (SS) Excessive focus on voluntarily meeting the I put others before myself.

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336 needs of others in daily situations, at the common reasons are: to prevent caus ing pain to others; to avoid guilt from feeling selfish; or to maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pain of others. Sometimes being adequately met and to resentment of those who are taken care of. (overlaps with sense of co dependency) Emotional inhibition (EI) The excessive inhibition of spontaneous action, feeling or communication usually to avoid disapproval b y others, feelings of shame, or common areas of inhibition involve: (a) inhibition of anger & aggression, (b) inhibition of positive impulses (e.g. joy, affection, sexual excitement, play); (c) difficulty expres sing vulnerability or communicating freely about emphasis on rationality while disregarding emotions. T o control my emotions. I think I continued to binge, purge, binge, pur ge were coming on so I began relying more on food to feel better. coming on so I began relying more on t he food to feel better. I think a lot I was just numb. In elementary school I was close to people and one minute they are your friends, and the next minute they are not.

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337 So if someone said something mean to me or whatever, flush it down the toilet. Failure to achieve (FA) The belief that one has fa iled, will inevitably fail, or is fundamentally inadequate relative to career, sports, etc). Often involves beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others etc. Not standing up for myself, in adequate, failure, stupid. Failure still stands out. Unrelenting standards/Hyper criticalness (US) The underlying belief that one must strive to meet very high internalized standards of behavior and performance, usu ally to avoid criticism. Typically results in feelings or pressure or difficulty slowing down; and in hypercriticalness toward oneself and others. Most involve significant impairment in: pleasure, relaxation, health, self esteem, sense of accomplishment, or satisfying relationships. Unrelenting standards typically present as (a) perfectionism, inordinate attention to detail, or performance is relative to the norm; (b) rigid including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that I am driven. I am v ery driven, compulsive. But when I set my mind do something I do get it d one. Sometimes I will sacrifice everything physically and mentally whateve r and ends up in a mess. I took that way to the max, over 500 miles that summer and that is when I end ed up in the hospital. You are looking good. You are running really fast and I was pushed to even do better than that. And so of course I wanted to succeed and thought losing a few pounds although I had lost a few running so the more I ran the more I lost. So at first it was a Compliments still were coming because I continued to lose weight and that summer after cross country

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338 more can be accomplished. and track my coach challenged me to run more than he did. I took that way to the max, over 500 miles that summer and that is when I ended up in the hospit al. Vulnerability to harm (VH) Exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the following: (a) medical catastrophe: e.g., heart attacks, AIDS; (b) emotional ca tastrophes e.g., going crazy (c) external catastrophes; e.g. elevators collapsing, victimized by criminals, airplanes crashes, earthquakes. Approval seeking/Recognition seeking (AS) Excessive emphasis on gaining approval, recognition, or attention from o ther people, or fitting in, at the expense of developing a secure dependent primarily on the reactions of others Sometimes includes an overemphasis on status, ap pearance, social acceptance, money, or achievement as mean of gaining approval, admiration, or attention (not primarily for power or control). Frequently results in major life decisions that are inauthentic or unsatisfying; or in hypersensitivity to rej ection. I was driven more by wanting to be accepted. I went to a small school and I had trouble with relationships and stu ff, not really fitting in. Negativity/Pessimism (NP) A pervasive, lifelong focus on the negative aspects of life (pain, death, los s,

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339 disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc) while minimizing or neglecting the positive or optimistic aspects. Usually includes an exaggerated expectation in a wide ra nge of work, financial, or interpersonal situations that things will ultimately fall apart. Usually Punitiveness (PU) The belief that people should be harshly punished for mistakes. Involves the tendency to be angry, intolerant, punitive, and impatie nt with those people (including oneself) who do Usually includes difficulty forgiving mistakes in oneself or others, because of a reluctance to consider extenuating circumstances, allow for human imperfection or e mpathize with feelings.

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340 Appendix O Coding Monica Anorexia Nervosa Category Definition Participant Statement Abandonment/Instability (AB) The perceived instability or unreliability of those available for support and connection. Involves t he sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable, unreliable, or erratically present; because they will die imm inently; or because they will abandon the patient in favor of someone better. Defectiveness/Shame (DS) The feeling that one is defective, bad, unwanted, inferior, or invalid in important respects; or that one would be unlovable to significant others if e xposed. May involved hypersensitivity to criticism, rejection, and blame; self consciousness, comparisons, and insecurity around others; or a sense of shame regarding private (e.g. selfishness, angry impulses, un acceptable sexual desires) or public (undesirable physical appearance, social Hello, she is a control freak. I would get into trouble for putting a spoon in the wrong drawer. And we probably did it multiple times. But putting it in the wro ng drawer would piss her off. She just right then I d If I had eaten a little bit of fat I might still feel guilty about it.

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341 awkwardness). Dep endence/Incompetence (DI) everyday responsibilities in a competent manner, without considerable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make goo d decisions). Often presents as helplessness. I find that I have a hard time making decisions without not that I have to consult her but I have make that decision. A $3.00 shirt sometimes can be hard an have to call my mom to buy a $3.00 shirt. Jus t by the frickin shirt. feel equipped to do what I am doing quite yet and so I still have a lot of anxiety about am I do ing this the right way? And I the problem is I felt horrible for doing it like that. And I ended up talking to one of the therapists about it because I felt so bad I had done that. That was so triggering. And the I am like, I t t he heck I am doing Emotional Deprivation (ED) of emotional support will not be adequately met by others. The three major forms of deprivation are: A. deprivation of Nurturance: Absence of attention, af fection, warmth, or companionship. B. Deprivation of Empathy: Absence of understanding, listening, self disclosure, or mutual sharing or feelings from others. Our re lationship is good but it is not what I want with him sometimes. He would never call me she is a rooster. The y ou are all wrong type.

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342 C. Deprivation of Protection: Absence of strength, direction, or guidance from others. Enmeshment (EM) Excessive emotional involvement and closeness wit h one or more significant others (often parents), at the expense of full individuation or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the oth er. May also include feelings of being smothered by, or fused with, others or insufficient individual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme Entitleme nt (ET) The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interactions. Often involves insistence that one should be able to do or have whatever on e wants, regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on superiority (being among the most successful, famous, wealthy) in order to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness

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343 controlling the behavior of others in line with without empathy or concern ds or feelings Insufficient Self Control (IS) Pervasive difficulty or refusal to exercise sufficient self control and frustration tolerance to impulses. In its m ilder form, patient presents with an exaggerated emphasis on discomfort avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion at the expense of personal fulfillment, commitment, or integrity. Mistrust/Abuse (MA) The expectati on that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually involves the perception that the harm is intentional or the result of unjustified and extreme negligence. May include the sense that one always ends up being c heated relative to Subjugation (SB) Excessive surrendering of control to others because one feels coerced usually to avoid anger, retaliation or abandonment. The two major forms of subjugation are: A. S preferences, decisions, and desires. B. Subjugation of Emotions: Suppression of emotional expression, especially anger. Usually

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344 opinions, and feelings are not val id or important to others. Frequently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Generally leads to a build up of anger, manifested in maladaptive symptoms (e.g., passive aggressive behavior, uncontrolled outburs ts of temper, psychosomatic symptoms, abuse. Social Isolation/Alienation (SI) The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or commun ity. Self Sacrifice (SS) Excessive focus on voluntarily meeting the needs of others in daily situations, at the expense reasons are: to prevent causing pain to others; to avoid guilt from feeling selfish; or t o maintain the connection with others perceived as needy. Often results from an acute sensitivity to the pain own needs are not being adequately met and to resentment of those who are taken care of. (over laps with sense of co dependency) Emotional inhibition (EI) The excessive inhibition of spontaneous action, feeling or communication usually to avoid disapproval by others, feelings of shame, or Sophomore year I dropped back down because I did rush and something terrible my best friend in. And had I been the person then that I am today I would have just said forget you

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345 common areas of inhibition involve: (a) inhibition of anger & aggression, (b) inhibition of positive impulses (e.g. joy, affection, sexual excitement, play); (c) difficulty expressing vulnerability or communicating freely about ssive emphasis on rationality while disregarding emotions. g uys but I d ropped back down to 95. Controlled my weight, ah controlled my emotions, I probably by not eating I probably controlled not my school work, but it was just another way it controlled everything. It was one of the things I was disciplined about. But probably more so my em otions were in control Failure to achieve (FA) The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to career, sports, etc). Often involve s beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc. Unrelenting standards/Hyper criticalness (US) The underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criticism. Typically results in feelings or pressure or difficulty slowing down; and in hypercriticalness toward oneself and others. Most involve significant impairment in: pleasure, relaxation, health, self esteem, sens e of accomplishment, or satisfying relationships. Unrelenting standards typically present as (a) perfectionism, inordinate attention to detail, or performance is relative to the norm; (b) rigid I am already a perfectionist and very controlling. I am very organized can be detail oriented. calories and my through process was almost like this obsession to not go over a certain amount of calor But part of my thinking about perfectionism and control ling was that this thing was something I at that time how to cope I was obses sed with calories and stuff.

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346 many areas of life, including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that more can be accomplished. But I remember looking at the calories and being obsessed about it. I wrote down how many ca lories were one point money on crappy stuff Because of my mom I am the way I am. The things that piss me off or create anxiety in me or I have realized just recentl y, or frustrate me, a ctually frustrated her. It is more of a way to control something and a way to cope. It is very much was a way to a I can control this. I had great disc ipline. I could be skinny. I do the check bo I have loosened my grip on some things. Just because I had to i I want to do the best job, and the best job to me is that you ha ve all the information.

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347 Vulnerability to harm (VH) Exaggerated fear that imminent catastrophe will strike a t any time and that one will be unable to prevent it. Fears focus on one or more of the following: (a) medical catastrophe: e.g., heart attacks, AIDS; (b) emotional catastrophes e.g., going crazy (c) external catastrophes; e.g. elevators collapsing, victi mized by criminals, airplanes crashes, earthquakes. My fear was I never wanted to be sent away. I t want to be sent away. Approval seeking/Recognition seeking (AS) E xcessive emphasis on gaining approval, recognition, or attention from other people, or fitting in, at the expense of developing a secure dependent primarily on the reactions of others natural inclinations. Sometimes includes an overemphasis on status, appearance, social acceptance, money, or achievement as mean of gaining approval, admiration, or attention (not primarily for power or control). Frequently results in major life decisi ons that are inauthentic or unsatisfying; or in hypersensitivity to rejection. counting calories and I kept it under 100. And I you discipline if I just had your about body image it was about the fact that oh look they think I am really in control. Oh ye ah people fed the disease. And you it was pretty m uch an identity thing for me. y image it was about the fact that oh look they think I am really in control Q: Are you a people pleaser A: It depends on who the person is professionally yes.

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348 Negativity/Pessimism (NP) A pervasive, lifelong focus on the negative aspects of life (pa in, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc) while minimizing or neglecting the positive or optimistic aspects. Usually includes an exaggerated expectation in a wide range of work, financial, or interpersonal situations that things will ultimately fall apart. Usually Punitiveness (PU) The belief that people should be harshly punished for mistakes. Involves the tendency to be angry, intolerant, punitiv e, and impatient with those people (including oneself) who do not includes difficulty forgiving mistakes in oneself or others, because of a reluctance to consider extenuating circumstances, allow for human imp erfection or empathize with feelings.

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349 Appendix P Coding Andrea Anorexia Nervosa Category Definition Participant Statement Abandonment/Instability (AB) The perceived instability or unreliability of those available for support and connection. Involves the sense that significant others will not be able to continue providing emotional support, connection, strength, or practical protection because they are emotionally unstable and unpredictable, unreliable, or erratically present; because they will die imminently; or because they will abandon the patient in favor of someone better. A fear of losing a family member. Him not loving me, no caring about me. And just that sense of rejection. Always a feeling of rejection. I was in seventh grade a nd a family friend that went to school with us, his parents were friends of my parents, made jokes about me being adopted and nd I was found in a dumpster. star ted questioning my place in the world and trying to understand why anybody would want to give you up and not understanding. Not knowing what to expect. Not knowing how I would react to them or how they would react to me and the fear of being rejected. B ecause that to me would horrifying. I was hurt I was hurt ca use I really felt rejected.

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350 So that is where a lot of this whole rejection came into play. Abandonment and not love and trying to find my place although I always had a place. That one incide nt in middle school caused me to it had a profound effect on me. That kid tell ing me I them to not love me. So I had to be there for him at all costs. At all costs. and why he would want to go away to school an d not be here with me. want to talk to me. I feel lik e she is rejecting me. Defectiveness/Shame (DS) The feeling that one is defective, bad, unwanted, in ferior, or invalid in important respects; or that one would be unlovable to significant others if exposed. May involved hypersensitivity to criticism, rejection, and blame; self consciousness, comparisons, and insecurity around others; or a sense of shame may be private (e.g. selfishness, angry impulses, unacceptable sexual desires) or public (undesirable physical appearance, social I started questioning my place in the world and trying to under stand why anybody would want to

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351 awkwardness). Dependence/Incompetence (DI) everyday responsibilities in a competent manner, without conside rable help from others (e.g., take care of oneself, solve daily problems, exercise good judgment, tackle new tasks, make good decisions). Often presents as helplessness. Emotional Deprivation (ED) degree of emo tional support will not be adequately met by others. The three major forms of deprivation are: A. deprivation of Nurturance: Absence of attention, affection, warmth, or companionship. B. Deprivation of Empathy: Absence of understanding, listening, sel f disclosure, or mutual sharing or feelings from others. C. Deprivation of Protection: Absence of strength, direction, or guidance from others. They were always proud of me but never w anted to tell me that. Enmeshment (EM) Excessive emotional involvem ent and closeness with one or more significant others (often parents), at the expense of full individuation or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the consta nt support of the other. May also include feelings of being smothered by, or fused with, others or insufficient I was that girlfriend that I had to be with him 24/. My world revolved around him. I would give up anything and everything to make sure tha t I could be with him. nothing for myself. Everything wa s around him, and everything was around my parents.

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352 individual identity. Often experienced as a feeling of emptiness and floundering, having no direction, or in extreme cases questioning xistence. Entitlement (ET) The belief that one is superior to other people; entitled to special rights and privileges; or not bound by the rules of reciprocity that guide normal social interactions. Often involv es insistence that one should be able to do or have whatever one wants, regardless of what is realistic, what others consider reasonable, or the cost to others; or an exaggerated focus on superiority (being among the most successful, famous, wealthy) in or der to achieve power or control (not primarily for attention or approval). Sometimes includes excessive competitiveness toward, or domination of point of view, or controlling the behavior of others in line with without feelings Insufficient Self Control (IS) Pervasive difficulty or refusal to exercise sufficient self control and frustration tolerance the impulses. In its milder form, patient presents with an exaggerated emphasis on discomfort

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353 avoidance: avoiding pain, conflict, confrontation, responsibility, or overexertion at the expense of personal fulfillment commitment, or integrity. Mistrust/Abuse (MA) The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage. Usually involves the perception that the harm is intentional or the result of unjustified and extreme neg ligence. May include the sense that one always ends up being But he was very abusive growing up. To my mom physically and verbally. Verb ally and emotionally to me. He knew that wa s one way to get to her. So I refused to live like that, I refused. The biggest impact was that I would go an get my education and me. I would be able to support myself no matter what and that was the mos t i mportant thing to me. along the line they are going to hurt me. The y going to reject me. What my dad did to my mom. What he put me trust he wi ll always be that way. Subjugation (SB) Excessive surrendering of control to others because one feels coerced usually to avoid anger, retaliation or abandonment. The two major forms of subjugation are:

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354 A. Subjugation of Needs: Suppression of B. Subjugation of Emotions: Suppression of emotional expression, especially anger. desires, opinions, and feelings are not valid or important to others. Frequ ently presents as excessive compliance, combined with hypersensitivity to feeling trapped. Generally leads to a build up of anger, manifested in maladaptive symptoms (e.g., passive aggressive behavior, uncontrolled outbursts of temper, psychosomatic sympt oms, withdrawal Social Isolation/Alienation (SI) The feeling that one is isolated from the rest of the world, different from other people, and/or not part of any group or community. Self Sacrifice (SS) Excess ive focus on voluntarily meeting the needs of others in daily situations, at the common reasons are: to prevent causing pain to others; to avoid guilt from feeling selfish; or to maintain the connection with ot hers perceived as needy. Often results from an acute sensitivity to the pain of others. Sometimes being adequately met and to resentment of those who are taken care of. (overlaps with I was the person he dumped on. I was the person call at 5:00 in the morning every time he was allowed to use the telephone I was that person. Q: When your brother was call from jail you said you were the one he called but you were also the one who answ ered, so did you struggle at all placing boundaries around his taking advantage of you. A: Oh absolutely. I had no boundaries. I sacrificed my education to try and b e there for my

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355 sense of co dependency) family. I had nothing I had lost all my goals, I had lost everything. Everything was around everyone else. And of course that was probably one of my biggest fears is that my parents would be hurt. The last thing I wa nted was to hurt them. At first I was very understanding because I was really trying to put myself in her p lace because that is the only way I am going to get through this without having a heart attack. And I kept thinking how she must feel. What she might think. That what would she want. So I was really trying to think of it from her perspecti ve. And I di t to scare her away. Emotional inhibition (EI) The excessive inhibition of spontaneous action, feeling or communication usually to avoid disapproval by others, feelings of shame, or los common areas of inhibition involve: (a) inhibition of anger & aggression, (b) inhibition of positive impulses (e.g. joy, affection, sexual excitement, play); (c) difficulty expressing

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356 vulnerability or communicating freely about emphasis on rationality while disregarding emotions. Failure to achieve (FA) The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to s of achievement (school, career, sports, etc). Often involves beliefs that one is stupid, inept, untalented, ignorant, lower in status, less successful than others, etc. Unrelenting standards/Hyper criticalness (US) The underlying belief that one mus t strive to meet very high internalized standards of behavior and performance, usually to avoid criticism. Typically results in feelings or pressure or difficulty slowing down; and in hypercriticalness toward oneself and others. Most involve significant impairment in: pleasure, relaxation, health, self esteem, sense of accomplishment, or satisfying relationships. Unrelenting standards typically present as (a) perfectionism, inordinate attention to detail, or perform ance is relative to the norm; (b) rigid including unrealistically high moral, ethical, cultural, or religious precepts; or (c) preoccupation with time and efficiency, so that I need to be perfect. So I had to in my mind create the perfect letter. And so it took me probably three days to write the letter. And I literally wrote, and wrote, and re wrote and I threw away and it had the perfect paper, it had to be the perfect pen, the handwr iti ng had to be perfect. For the next two years I spent every time the phone I became obsessed with who was calling. If I was unavailable I always answered it. It was an obsessed with who was calling. If I was unavailable I always answered it. If it w know I answered it. If they hung up on me I would go online and research trying to find them. I went as far as to find where they lived, how far that

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357 more can be accomplished. would be from me. Was it possible that they could have been who it was. It was i nsane. It was awful. Every birthday I just knew she was going to call. ) Vulnerability to harm (VH) Exaggerated fear that imminent catastrophe will strike at any time and that one will be unable to prevent it. Fears focus on one or more of the followin g: (a) medical catastrophe: e.g., heart attacks, AIDS; (b) emotional catastrophes e.g., going crazy (c) external catastrophes; e.g. elevators collapsing, victimized by criminals, airplanes crashes, earthquakes. o have to go through what they went through. Because I think my dad was abusive to them physically now that I look back at it as an adult. trie d to be the model child I was determined to never be involv ed with anybody like him. I would not date anybody who would drink to access or I felt my boyfrie nd ever got intoxicated. Approval seeking/Recognition seeking (AS) Excessive emphasis on gaining approval, recognition, or attention from other people, or fi tting in, at the expense of developing a secure dependent primarily on the reactions of others Sometimes includes an overemphasis on status, appearance, social a cceptance, money, or achievement as mean of gaining approval, admiration, or attention (not primarily for power or control). Frequently results in major life decisions that are inauthentic or Because she was going to judge me based on this. I continued to battle with eating because it was still that he is trying to live his life and do what he way I wanted him to. If I gained w eight he would want me

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358 unsatisfying; or in hypersensitivity to rejection. Negativity/Pessimism (NP) A pervasive, lifelong focus on the negative aspects of life (pain, death, loss, disappointment, conflict, guilt, resentment, unsolved problems, potential mistakes, betrayal, things that could go wrong, etc) while minimizing or neglecting the positive or optimistic aspects. Usually includes an exaggerated expectation in a wide range of work, financial, or interpersonal situations that things will ultimately fall apart. Usually Punitiveness (PU) The belief that people shou ld be harshly punished for mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with those people (including oneself) who do Usually includes difficulty forgiving mistakes in oneself o r others, because of a reluctance to consider extenuating circumstances, allow for human imperfection or empathize with feelings.

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359 Appendix Q Auditor Background Information I have been a counselor for the past five years and have been licensed in the State of Florida as a Mental Health Counselor for approximately 2 years (LMHC # 9747). My work has included serving as a counselor for the Counseling Center at the University of South Florida Polytechnic, as Adjunct Professor with the College of Educatio n also at the University of South Florida Polytechnic and now currently as a private practitioner. My knowledge of eating disorders is modest. I did however, during the course of my r treatment for eating disordered individuals within the Polk County vicinity. I her stems from working together within the Counseling Center. This is my first exper ience for an auditor for a dissertation Sincerely, Cara M. Hewett, Licensed Mental Health Counselor

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360 Appendix R Letter of Attestation February 20, 2010 To Whom It May Concern, My instruction was to assume the responsibility of auditor for the disse rtation of Susan Hurley, doctoral candidate with the Division of Psychological and Social Foundations, Division of Counselor Education in the College of Education at the University of South Florida. My role as auditor was to ensure dependability, confirm ability, and credibility of schema associated with anorexia nervosa, bulimia nervosa and compulsive overeating resulting in obesity. My roles and responsibilities as aud itor of this dissertation were: 1) to review and verify the data gathered from the research participants and 2) to attest to having done so. The steps I followed in the audit process were as follows: Familiarized myself with the study by reading Chapter Three of the dissertation proposal. Familiarized myself with the responsibilities of an auditor by meeting with Ms Hurley to discuss her expectations. coding criteria established by Ms Hurley. Read the interviews of the 10 research participants Ensured dependability by examining the process of inquiry, i.e., the questions asked of each participant, responses by the researcher, as well as the product, i.e., data, findings, and interpret ations of the researcher. Ensured confirmabilty by, examining analytical techniques used by the researcher, agreeing upon appropriateness of coding labels, discussing Made notes while reading the interviews and shared notes with Ms Hurley. Ensured credibility by providing peer debriefing to the researcher. We talked on the pone and in person on several occasions exploring her findings, clarifying interpretations of the dat a, and discussing the overall process of her study. I was able to find and confirm dependable the research findings that Ms Hurley reported. No inconsistencies, illogical inferences, or researcher bias were found during the course of this study therefore making the research credible. Sincerely, Cara M. Hewett, Licensed Mental Health Counselor

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About The Author accepted a position as Coordinator if the Division of Education a t the University of South Florida Polytechnic (USFP). As she began working on campus she became aware of a lack of counseling services for students attending classes at USFP. She found an open office on the campus, and made a proposal to the administrati on to provide counseling services to students on campus. One of the first clients to seek counseling was a young woman diagnosed with Anorexia Nervosa. Through the process of helping her, Susan became very aware of the difficulties of treating disordered eating. Thus began her interest in researching possible treatment options in order to offer this student the best possible treatment available. This dissertation is the culmination of her research and effort to add to the body of research in the field. Her hope is that the information found in this dissertation will help her and others pursue better treatment options for disordered eating. Susan continues to work at the University of South Florida Polytechnic. Over the course of eight years she has dev eloped the counseling center, moving it from a quarter time position to a full time position with two mental health counselors seeing students with mental health, substance abuse and other issues. Recently she was named as the Program Director of Student Health and Wellness.