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EATBEH-00729; No of Pages 5

Contents lists available at ScienceDirect

Eating Behaviors

Comprehensive examination of the trans-diagnostic cognitive behavioralmodel of eating disorders in males

OFAntonios Dakanalis a,⁎, C. Alix Timko b, Massimo Clerici c, M. Assunta Zanetti a, Giuseppe Riva d

a Department of Brain and Behavioural Sciences, University of Pavia, Italyb Behavioral and Social Sciences Department, University of the Sciences, Philadelphia, PA, USAc Department of Neurosciences and Biomedical Technologies, University of Milano-Bicocca, Italyd Faculty of Psychology, Applied Technology for Neuro-Psychology Laboratory, Istituto Auxologico Italiano, Catholic University of Milan, Milan, Italy

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⁎ Corresponding author at: Department of Brain and BehPavia, P.za Botta 11, 27100, Pavia, Italy.

E-mail address: antonios.dakanalis@unipv.it (A. Dakan

1471-0153/$ – see front matter © 2013 Published by Elsehttp://dx.doi.org/10.1016/j.eatbeh.2013.10.003

Please cite this article as: Dakanalis, A., et al.,in males, Eating Behaviors (2013), http://dx.d

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Article history:Received 19 December 2012Received in revised form 19 August 2013Accepted 9 October 2013Available online xxxx

Keywords:Cognitive–behavioralTrans-diagnostic ModelEating disordersMenStructural equation modeling

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The Trans-diagnostic Model (TM) of eating pathology describes how one or more of four hypothesizedmechanisms (i.e., mood intolerance, core low self-esteem, clinical perfectionism and interpersonal difficulties)may interrelate with each other and with the core psychopathology of eating disorders (i.e., over-evaluation ofweight and shape) to maintain the disordered behaviors. Although a cognitive behavioral treatment based onthe TMhas shown to be effective in treating eating disorders, themodel itself has undergone only limited testing.This is the first study to both elaborate and test the validity of the TM in a large sample (N = 605) ofundergraduate men. Body mass index was controlled within structural equation modeling analyses. Althoughnot all expected associations for the maintenance variables were significant, overall the validity of the modelwas supported. Concern about shape and weight directly led to exercise behaviors. There was a direct pathfrom binge eating to exercise and other forms of compensatory behaviors (i.e., purging); but no significantpath from restriction to binge eating. Of the maintaining factors, mood intolerance was the only maintainingvariable directly linked to men's eating disorder symptoms. The other three maintaining factors of the TMindirectly impacted restriction through concerns about shape andweight, whereas only interpersonal difficultiespredicted low self-esteem and binge eating. Potential implications for understanding and targeting eatingdisturbances in men are discussed.

© 2013 Published by Elsevier Ltd.

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RR1. Introduction

The Trans-diagnosticModel (TM; Fairburn, Cooper, & Shafran, 2003)of eating pathology was developed in order to recognize the commonfeatures of all eating disorders (EDs) and the high rate of diagnosticcrossover (Fairburn & Cooper, 2011). At its core is an over-evaluationof weight and shape and attempts to control them. The attempts atcontrol manifest as severe restriction, which in turn exacerbates shapeand weight concerns (SWCs) and can lead to further restriction or abinge/purge cycle. What is unique about the TM is that it posits thatsome individuals may struggle in one of four areas hypothesized tomaintain EDs: clinical perfectionism, core low self-esteem, moodintolerance, and/or interpersonal difficulties (Cooper & Fairburn, 2011).

Although randomized controlled trials (Fairburn et al., 2009)provide preliminary support for the efficacy of the Cognitive BehavioralTherapy—Enhanced (CBT-E; Fairburn, 2008), good treatment outcomedoes not necessarily constitute evidence for the adequacy of the TMon which the treatment is based. Recently, there has been increasedfocus on testing the validity of the conceptual relationship of the TM

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Comprehensive examinationoi.org/10.1016/j.eatbeh.2013

in both clinical and non-clinical female samples (e.g., Hoiles, Egan, &Kane, 2012; Lampard, Byrne, McLean, & Fursland, 2011; Schnitzler,von Ranson, & Wallace, 2012; Tasca et al., 2011). Overall data fromthese studies tended to support the validity of the TM in women.

1.1. Rationale and aims

The lack of a direct comprehensive evaluation of the TM of EDs inmen is somewhat surprising, given that men and women are moresimilar than dissimilar in terms of core ED behaviors (i.e., comparablerestriction and binge eating rates), though they differ in the frequencyof certain compensatory behaviors (Hudson, Hiripi, Pope, & Kessler,2007; Lavender, De Young, & Anderson, 2010). There is a comparablerate of excessive exercise between young men and women, but lowerlevels of purging among men (Lavender et al., 2010; Striegel-Mooreet al., 2009). Although the main purpose of compensatory behaviors isto counteract the effects of eating in order to avoid weight gain, inmen, who tend to be more preoccupied with enhancing musculature(Dakanalis & Riva, 2013), exercise is not exclusively in the serviceweight reduction, but may also be utilized for the purpose of musclemass gain (Anderson & Bulik, 2004). According to the TM, all formsof EDs should represent varying behavioral expressions of SWCs(Fairburn et al., 2003). However, given the different nature of SWCs in

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men, the dual function of exercise behavior, and the different ratesof certain compensatory behaviors, it is unclear if and how the TMfits men.

The goals of the current studywere to (a) test the TM among collegemen, who are recognized as a “high” risk group for the onset of harmfuleating and body-related disordered behaviors (Hudson et al., 2007),and (b) consider exercise and other forms of compensatory behaviors(i.e., purging, fasting) separately in the evaluation of the model, asrecommended (Anderson & Bulik, 2004). Our hypothesized model,depicted in Fig. 1A was analyzed using a structural equation modelingin which the specification of the structural relationships was based on

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Fig. 1. This figure represents the hypothesized Trans-diagnostic Model of eating disorders in mpaths added (B). Singe-headed and double-headed arrows represent the impact of one variabthe structural model are presented. *p b .05.

Please cite this article as: Dakanalis, A., et al., Comprehensive examinationin males, Eating Behaviors (2013), http://dx.doi.org/10.1016/j.eatbeh.2013

the illustrations of the TM model and men's ED literature (Dakanalis &Riva, 2013; Fairburn et al., 2003).

2. Methods

2.1. Participants

Participants were 613 men ranging in age from 18 to 30 (M=20.64,SD=4.3) recruited from four large universities in Italy. The majority ofthe sample (95%) is identified asWhite/European (95%) andheterosexual(93%). Average body mass index (BMI=kg/m2), was 23.90 (SD=4.2).

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en (A) and the final structural model with non-significant paths trimmed and significantle on other and correlations between pairs of variables, respectively. Path coefficients for

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1 The results of bootstrapping (available from the authors upon request) indicated thatall indirect effects of the final structural model were significant.

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2.2. Instruments

Thirteen selective scales or subscales of the Italian validated versionsof seven instruments with well-established psychometric proprietiesamong college-aged men were used in the current study. Their singleitems or a combination of scales or subscales were used as indicatorvariables (Byrne, 2011) of nine latent variables (Fig. 1A).

Scales of the Eating Disorder Inventory—3 (Garner, 2008) were usedto measure mood intolerance (via the eight items of the emotionaldysregulation scale), low self-esteem (via the six items of self-esteemscale), binge eating (via the eight items of the bulimia scale) andinterpersonal difficulties (via the 7-item interpersonal insecurity scaleand the 7-item interpersonal alienation scale).

The 9-item Male Body Dissatisfaction Scale (Dakanalis, Timko et al.,in press) and the 4-item appearance intolerance subscale of the MuscleDysmorphia Disorder Inventory (Santarnecchi & Dèttore, 2012) wereused to measure male SWCs.

The six exercise strategies subscale items of the Body ChangeInventory (Bastianelli, Vicentini, Spoto, & Vidotto, 2007), which assessthe frequency of exercise to reduce fat/weight and increasemuscularity,were used to measure exercise behavior.

Three subscales of the Frost Multidimensional PerfectionismScale (Lombardo, 2008) were used to measure clinical perfectionism —

personal standards (7 items), concern over mistakes (9 items), anddoubts about action (4 items).

The five restraint subscale items of the Eating Disorder ExaminationQuestionnaire — Version 6 (Fairburn, 2010) were used to measuredietary restriction.

The five compensatory behavior subscale items of the BulimicInvestigatory Test, Edinburgh — Severity Index (Orlandi, Mannucci, &Cuzzolaro, 2005), which assess the frequency/severity of methods forcounteract the effects of bing eating (i.e., fasting, purging), were usedto measure other forms of compensatory behaviors.

2.3. Procedure

Participants were recruited via advertisements posted in academicdepartments in four large universities in Italy. The research advertise-ments directed interested participants to a web page that provideddetails about the study. After indicating their consent, participantscompleted the study's measures, which were presented in a counter-balanced order and formatted so that participants could not skipindividual items (Dakanalis, Zanetti, Rival et al., in press). Severalstrategies were used to reduce the likelihood of erroneous dataincluding the insertion of a validity question in each measure,checking the IP address of all participants, and evaluating forthe presence of outliers. After these procedures, data from 605 menremained for analysis. All procedures were approved by theappropriate ethics board.

2.4. Statistics

The “measurement model” was first tested for acceptable fit to thedata using confirmatory factor analysis (CFA) and then the “structuralmodel” (Fig. 1A) was tested (Byrne, 2011); BMI was a covariate inthis model (Stice, 2002). Both models were examined using themaximum-likelihood method (as pre-analysis did not revealed anyevidence for non-normality) in Mplus 5.1 (Muthén & Muthén,1998–2007). Criteria for good model fit were a comparative fit index(CFI) and a Tucker–Lewis index (TLI) of .95 or greater, a standardizedrootmean square residual (SRMR) of .08 or less, and a rootmean squareerror of approximation (RMSEA) of .06 or less (Byrne, 2011). Weplanned to trim non-significant structural paths and to add paths notoriginally specified but that impacted the fit of the model to the databased on the modification index values (MIs N 5.0); the chi-squaredifference (Δχ2) was used to compare nested models (Byrne, 2011).

Please cite this article as: Dakanalis, A., et al., Comprehensive examinationin males, Eating Behaviors (2013), http://dx.doi.org/10.1016/j.eatbeh.2013

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3. Results

Descriptive statistics, internal reliability estimates of each measureand partial correlations (holding BMI as a covariate) are shown inTable 1.

A CFA testing the relationships between the measured and latentvariables indicated a good model fit: CFI= .97, TLI= .96, SRMR= .06,RMSEA= .04. All loadings (ranging from .80 to .93) were significant at.001 level; therefore, all latent factors were adequately operationalizedthrough their respective indicators.

The structural model fit the data well: CFI= .95, TLI= .95, SRMR=.07, RMSEA = .05. However, restriction did not predict binge eating,while all other specified paths were statistically significant (Fig. 1B).The trimmed model, in which the non-significant path was deleted,did not result in decreased model fit [CFI= .95, TLI= .95, SRMR= .07,RMSEA=.05; Δχ2 (1, N=605)= .99, pN .05] and thus was retained.

Three un-estimated paths with a value N5.0 were noted in thetrimmed model: the paths frommood intolerance to dietary restrictionand exercise behavior and the path from interpersonal difficulties tobinge eating. The revised model, in which these paths were added(CFI=.96, TLI=.96, SRMR=.06, RMSEA=.04), provided a significantlybetter fit than the trimmed model, Δχ2 (3, N=605)=37.09, p b .001,and consequently was retained. The significant structural coefficientsfrom this final structural model1 are presented in Fig. 1B.

Interpersonal difficulties, core low self-esteem, and clinical perfect-ionism predicted 52.8% of the variance in SWCs. Mood intolerance andSWCs accounted for 35.3% of the variance in restriction. Binge eating,SWCs, and mood intolerance contributed 29.1% of the variance inexercise behavior. Binge eating and mood intolerance predicted 14.9%of the variance in other forms of compensatory behaviors. Finally,mood intolerance and interpersonal difficulties predicted 41.6% of thevariance in binge eating.

4. Discussion

Consistent with previous studies that examined the validity of TM ofEDs in female clinical and community samples (Hoiles et al., 2012;Lampard et al., 2011; Schnitzler et al., 2012; Tasca et al., 2011), wefound that (a) interpersonal difficulties were directly linked to lowself-esteem, (b) there is a direct path frombinge eating to compensatorybehaviors and (c) clinical perfectionism, low self-esteem and inter-personal difficulties only indirectly influence restriction through SWCs,highlighting the importance of over-evaluation with one's appearance.The results of this study indicate that men differ from women in termsof the TM due to the direct impact that SWCs have on the likelihood ofexercising. This is in-line with literature indicating that men are morelikely to use exercise to reduce subcutaneous fat and increase muscledefinition (Dakanalis & Riva, 2013).

Mood intolerance was the only maintaining variable directly linkedto restriction. The significant relationships between binge eating, otherforms of compensatory behaviors, and mood intolerance are in-linewith TM. These behaviors are believed to have an emotional regulatoryfunction and to occur in attempt to reduce negative affect (Gross, 2007).Although the direct paths between mood intolerance, restriction, andexercise support this hypothesis, replication of these findings is needed.

Surprisingly, there was no direct relationship between restrictionand binge eating. Although this goes against a central assumption ofthe TM, there is increasing evidence that restriction does not alwayslead to binge eating (e.g., Dakanalis, Zanetti, Clerici et al., in press;Lampard et al., 2011; Spoor et al., 2006). The direct paths from inter-personal difficulties and mood intolerance to binge eating, as well asevidence that healthy-weight treatment programs for EDs and inter-ventions that do not focus on reducing restriction (i.e., interpersonal

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Table 1t1:1

t1:2 Means, standard deviations (SDs), Cronbach's alpha coefficients, and partial correlations (with body mass index controlled).

t1:3 Measures 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

t1:4 1. EDI3-II –

t1:5 2. EDI3-IA .64⁎ –

t1:6 3. EDI3-LSE .23⁎ .19⁎⁎ –

t1:7 4. MPS-CM .18⁎⁎ .17⁎⁎ .20⁎ –

t1:8 5. MPS-PS .20⁎ .18⁎⁎ .30⁎ .59⁎ –

t1:9 6. MPS-DA .24⁎ .26⁎ .31⁎ .56⁎ .67⁎ –

t1:10 7. EDI3-ED .22⁎ .23⁎ .32⁎ .28⁎ .10 .09 –

t1:11 8. MBDS .47⁎ .46⁎ .51⁎ .54⁎ .55⁎ .56⁎ .08 –

t1:12 9. MMDI-AI .45⁎ .44⁎ .50⁎ .55⁎ .60⁎ .49⁎ .06 .74⁎ –

t1:13 10. EDEQ-R .14⁎⁎⁎ .13⁎⁎⁎ .09 .17⁎⁎⁎ .15⁎⁎⁎ .14⁎⁎⁎ .28⁎ .68⁎ .75⁎ –

t1:14 11. EDI3-BL .54⁎ .46⁎ .10 .05 .04 .03 .64⁎ .03 .05 .23⁎⁎ –

t1:15 12. BCI-ES .12⁎⁎⁎ .14⁎⁎⁎ .14⁎⁎⁎ .18⁎⁎⁎ .17⁎⁎⁎ .15⁎⁎⁎ .24⁎ .33⁎ .30⁎ .09 .33⁎⁎ –

t1:16 13. BITE-CB .03 .02 .06 .03 .05 .04 .29⁎ .08 .09 .10 .30⁎⁎ .09 –

t1:17 α .90 .94 .91 .90 .93 .90 .92 .90 .89 .90 .92 .92 .87t1:18 M 27.80 25.10 21.89 21.20 19.80 10.02 36.05 40.94 14.77 20.18 33.11 16.99 9.10t1:19 SD 19.13 17.90 15.74 6.12 6.76 3.77 15.01 16.86 6.06 14.30 21.55 5.89 4.40t1:20 Scale range 7–42 7–42 6–36 9–45 7–35 4–20 8–48 9–54 4–20 0–30 8–48 6–30 0–35

t1:21 Note. N=605. EDI3-II, IA, LSE, ED, and BL=Eating Disorder Inventory—3, Interpersonal Insecurity scale, Interpersonal Alienation scale, Low Self-Esteem scale, Emotional Dysregulationt1:22 scale, and Bulimia scale, respectively;MPS-CM, PS andDA=Multidimensional PerfectionismScale, Concern overMistakes subscale, Personal Standards subscale, andDoubts aboutActionst1:23 subscale, respectively; MBDS = Male Body Dissatisfaction Scale; MMDI-AI = Muscle Dysmorphia Disorder Inventory, Appearance Intolerance subscale; EDEQ-R = Eating Disordert1:24 Examination Questionnaire—Version 6, Restraint subscale; BCI-ES = Body Change Inventory, Exercise Strategies subscale; BITE-CB = Bulimic Investigatory Test Edinburgh—Severityt1:25 Index, Compensatory Behaviour subscale.

⁎ p b .001.t1:26⁎⁎ p b .01.t1:27⁎⁎⁎ p b .05.t1:28

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psychotherapy) also decrease binge eating relative to assessment-onlycontrol conditions (e.g., Agras, Walsh, Fairburn, Wilson, & Kraemer,2000; Burton & Stice, 2006) lend credence to the hypothesis that factorsother than restrictionmay play a critical role in the devolvement and/ormaintenance of binge eating (e.g., Hopwood, Clarke, & Perez, 2007;Lampard et al., 2011).

Menwith clinical or subclinical levels of EDsmay benefit from CBT-E(Fairburn, 2008), which targets the maintenance variables relevant toeach individual in addition to SWCs. If our results are confirmed infuture studies, men's ED prevention programs could be designed totarget male body concerns and mood intolerance in order to indirectlyand directly reduce men's eating disordered behaviors (Dakanalis &Riva, 2013).

4.1. Limitations

The sample mainly consisted of white heterosexual college-agedmen; potentially impacting generalizability. Future research shouldascertain whether these results could be replicated in a male clinicalsample and in men of different sexual orientation and of variousethnicities (Dakanalis et al., 2012). The cross-sectional design of thisstudy does not permit examination of causal relationships and feedbackmaintenance loops within the model (i.e., if the use of compensatorybehaviors encourage further binge eating) and therefore, enhancedexperimental and longitudinal design are needed.

4.2. Conclusions

Although the predicted relationship between restriction andbinge eating was not supported, the TM appears to fit male EDsymptomatology. Data from this study highlight the possibilitythat difficulties in emotional regulation may play a role in all formsof men's disordered eating behaviors.

Role of funding sourcesThere were no funding sources for this study and/or preparation of the manuscript.

ContributorsAuthors A.D., M.C., and A.M.Z., designed the study. Authors C.A.T., A.D. and G.R. wrote

the manuscript. Authors A.D. and G.R. conducted the statistical analysis. Authors M.C.,

Please cite this article as: Dakanalis, A., et al., Comprehensive examinationin males, Eating Behaviors (2013), http://dx.doi.org/10.1016/j.eatbeh.2013

ED C.A.T., and A.M.Z., conducted literature searches to provide background literature and

situate the study within the current state of the field. All authors have approved thisfinal version of the manuscript.

Conflict of interestAll authors declare that they have no conflicts of interest.

AcknowledgmentsThe authors would like to thank Laura Favagrossa, Valentina E. Di Mattei, Fabio

Madeddu and Lucio Sarno, and Kelly Cuccolo for their help with this manuscript.

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