International Journal of Arts and Sciences 3(9): 92 - 101 (2010) CD-ROM. ISSN: 1944-6934 © InternationalJournal.org

Two Important Contributors to Bulimia Nervosa among Women: Alexithymia as a Form of Emotion Dysregulation and Media Induced Body Dissatisfaction Shannon Sullivan, Brigham Young University, USA Karen E. Hyer, Brigham Young University, USA

Abstract: Bulimia nervosa is an eating disorder defined by the consumption of large amounts of food followed by unhealthy compensatory measures to rid the body of the food consumed. These compensatory methods include excessive exercise, fasting, and vomiting. It is estimated that 6% of teenage girls and 5% of college-aged women suffer from bulimia. In recent years, 40% of college women reported participating in bulimic behaviors. Once initiated, bulimia is often a lifetime disorder with several side effects, including irritable bowel syndrome, mood and personality disorders, substance abuse, poor impulse control, anxiety disorders, and esophageal bleeding. Numerous studies have been performed to pinpoint why the disorder proves so alluring for females in particular. Recent research suggests that women exhibiting emotion dysregulation signs of alexithymia—difficulty distinguishing between physical sensations (such as hunger) and emotional stress—are at greater risk for developing the disorder. Additionally, recent studies indicate that women with poor body image, often brought on by unhealthy media influences of beauty norms and body size, are also at increased risk for bulimia. This paper proposes that professional consideration of alexithymia as a form of emotion dysregulation and media induced body dissatisfaction will enable the prevention of bulimia in women prone to the disorder, as well as the development of better treatment programs for women already suffering from bulimia nervosa.

Introduction Bulimia nervosa is an eating disorder defined by the consumption of large amounts of food followed by unhealthy compensatory measures to rid the body of the food consumed. Though vomiting is often thought of as the one compensatory measure used to cleanse the body of food, the act of vomiting is not required to diagnosis one as bulimic. There are two diagnostic categories of bulimia nervosa: the purging and nonpurging kind. The purging category of bulimia is the compensatory measure most often associated with the disorder, where one vomits after consuming a large amount of food. The non-purging sub-category of bulimia nervosa consists of riding the body of consumed food through other unhealthy measures, such as use of laxatives, fasting, and extreme exercise on the days following a binge. Women are more likely to prescribe to bulimic behaviors than men, with women estimated as making up 90-95% of bulimics. Caucasian women seem more at risk for the disorder than other races and ethnicities. Onset of bulimia usually occurs at 18 years in women, though many women do not acquire the disorder until age 25 or older. It is

International Journal of Arts and Sciences 3(9): 92 - 101 (2010) CD-ROM. ISSN: 1944-6934 © InternationalJournal.org

estimated that 6% of teenage girls and 5% of college-aged women suffer from bulimia. Indeed, in recent years, 40% of college-aged women reported participating in bulimic behaviors. These statistics alone are saddening. However, as those suffering from bulimia nervosa are usually secretive about the behavior, it is extremely difficult to know with surety how accurate reported percentages of bulimia are, as most women will hide the disorder from even their closest friends and family members. Recovery rates from bulimia nervosa are not encouraging, and bulimic pathology is often chronic: “a community-recruited natural history study found that only 49% of women with bulimia nervosa showed lasting remission from bulimic behaviors over 5 years” (Bohon, Stice, & Burton, 2008, p. 173). Once initiated, bulimia is often a life-time disorder with several health problems as side effects, including irritable bowel syndrome, mood and personality disorders, substance abuse—particularly alcohol, poor impulse control, anxiety disorders, and esophageal bleeding. With so many undesirable side effects, the question of what motivates women to participate in bulimic behaviors arises. Copious research and studies have been performed to pinpoint why the disorder proves so alluring for females in particular. Many conclude that bulimia nervosa continues to be a problem for women due to the ability of the disorder to act as a coping mechanism: after a long, stressful day, binging on comfort food followed by a purge is an outlet some women choose in order to relax and forget about the intricacies of life. It is only a measure of temporary relief, however; for the binge-purge cycle does not alleviate the problems of life or make them go away. Thus the cycle perpetuates, leading to an addiction almost impossible for many women to break free from. Other studies evidence that women suffering from bulimia nervosa acquired the disorder through alexithymia, a form of emotion dysregulation where one has difficulty distinguishing physical sensations, such as hunger, from emotional feelings, such as stress. Recent research concludes that women with alexithymia may be more prone to acquire and maintain bulimic behaviors, as they may be unable to discriminate between physical hunger and emotional highs and lows. Though some women may resort to bulimia nervosa as a coping mechanism, or acquire the disorder through emotion dysregulation in the form of alexithymia, other studies indicate that many women turn to bulimia because of extreme body dissatisfaction, often induced by the media. These women use the disorder as a weight-control method and in turn become addicted to bulimic behavior through the temporary relief and euphoria the disorder may bring about. Many women today are dissatisfied with their bodies and go to extreme measures to conform to the Western ideal of the un-healthfully slim female body as portrayed in the media. When other dieting and exercise measures have failed, some women turn to bulimia to achieve the impossibly unrealistic body standards they have set for themselves through media influences.

International Journal of Arts and Sciences 3(9): 92 - 101 (2010) CD-ROM. ISSN: 1944-6934 © InternationalJournal.org

The reasons why women subscribe to eating disorders like bulimia nervosa must be publicized. Through greater public knowledge of factors that influence women to resort to the disorder, such as difficulty distinguishing between physical sensations and emotions brought on by the emotion dysregulation of alexithymia, and use of the disorder to conform to unrealistic media portrayals of the female body, we can better help women steer clear of the disorder. Indeed, knowledge of these factors that influence the occurrence bulimia nervosa could be beneficial for preventing the disorder in women. Furthermore, awareness of these influencing factors would help improve the effectuality of treatment programs for those already suffering from bulimia, thus hopefully raising the percentage of full recoveries from the disorder. It is hypothesized that a literature review and analysis of studies highlighting possible causes for bulimia nervosa among women will support the truthfulness of suppositions that emotion dysregulation in the form of alexithymia and media induced body dissatisfaction act as contributing factors to the development of bulimic behaviors in women.

Methodology This literature review will spotlight a myriad of articles highlighting contributors to bulimia nervosa. Through this spotlighting, the objective of condensing a vast amount of research into a comprehensive, summarized format for those seeking understandable information regarding two important factors that influence the occurrence of bulimia nervosa in women will be achieved. Additionally, it is hoped that the summarized presentation of the copious amount of information available on two important contributors to bulimia nervosa will lead readers to share these facts and theories with friends and loved ones. The spreading of this information will hopefully prove a preventative measure to bulimic behavior by perhaps helping women alert themselves to signs of emotion dysregulation in their own eating patterns and habits: awareness of the diagnostic definition of alexithymia may encourage women to evaluate their hunger and emotion categorization processes. It is also hoped that the presentation of information regarding influencing factors of bulimia will help women realize just how warped their body image perceptions, and the body standards presented in the media, can truly be. Hopefully this realization will help foster a more satisfied body image in many women. Perhaps a spreading of this information will also inspire the media to present more realistic body images that impressionable women will feel are not impossible to emulate. Indeed, this could help many women become more satisfied with their bodies and help prevent bulimic behaviors.

Results According to Jumi Hayaki, “recent evidence indicates that emotion dysregulation or difficulties in the expression and modulation of emotional experience may constitute an important factor in the etiology and maintenance of BN [bulimia nervosa]” (Hayaki, 2008, p. 552). Hayaki measured this emotion dysregulation by conducting a self-reported survey of 115 under-graduate-aged women. In the survey, these women were asked

International Journal of Arts and Sciences 3(9): 92 - 101 (2010) CD-ROM. ISSN: 1944-6934 © InternationalJournal.org

questions regarding alexithymia, a form of emotion dysregulation defined as difficulty identifying feelings and distinguishing emotions from physical sensations. The questions were taken from the 20 Item Toronto Alexithymia Scale, the most widely used scale for measuring alexithymia. The scale asks a series of twenty questions, with patients answering each question on a scale from one (strongly disagree) to five (strongly agree). 1 Scores range from twenty to one hundred and a score greater or equal to sixty-one diagnoses one with alexithymia. In addition, the participants were asked questions about “experiential avoidance, defined as an unwillingness to remain in contact with unpleasant cognitive, physical, and emotional processes” (Hayaki, 2008, p. 552). Questions regarding symptoms of bulimia nervosa in the women were also posed, using the Bulimia Test-Revised, a widely used self-report method to measure the indicators or prevalence of bulimia. Eight of the thirtysix questions on the Bulimia Test-Revised “are considered diagnostic and are not scored; the scored portion ranges in score from 20 to 140, with higher scores indicating greater severity in BN” (Hayaki, 2008, p. 553). The survey participants were also asked questions from The Eating Expectancy Inventory regarding their eating expectancies, defined as expectancies learned through one’s life about food: does food act as an appropriate reward for good behavior or work? Does eating effectively alleviate boredom? Hayaki’s results found that women who scored high on the Bulimia Test-Revised, showing greater severity of bulimia nervosa, also scored greater or equal to sixty-one on the Toronto Alexithymia Scale, diagnosing them with alexithymia. These findings firmly support the correlation between alexithymia and the occurrence of bulimia nervosa. The women who viewed food as a reward or activity to alleviate boredom on the eating expectancy questions of The Eating Expectancy Inventory were also more likely to subscribe to bulimic behaviors, further supporting theories that women suffering from forms of emotion dysregulation are at greater risk for developing and continuing bulimia behaviors. A study by Carano et al. supports the results of Hayaki regarding the correlation between bulimia nervosa and emotion dysregulation problems such as alexithymia. In Carano’s study, 101 patients with bulimia nervosa or binge eating disorder were evaluated. 2 The 1

Questions on the scale include such emotion identification related inquiries as “I sometimes experience confusing sensations in my body,” “When asked which emotion I’m feeling, I frequently don’t know the answer,” “I’m unsure of which words to use when describing my feelings,” “When I am upset I find it difficult to identify the feelings causing it.” 2 Carano, De Berardis, Gambi, di Paolo, Campanella, Pelusi, Sepede, Mancini, La Rovere, Salini, Cotellessa, Salerno, and Ferro (2005) define binge eating disorder as “a newly recognized diagnostic entity characterized by episodes of uncontrolled consumption of large amounts of food, similar to those experienced by individuals with

International Journal of Arts and Sciences 3(9): 92 - 101 (2010) CD-ROM. ISSN: 1944-6934 © InternationalJournal.org

patients in the Carano et al. study were asked questions from the Body Shape Questionnaire-Short Version (BSQ-S), the Body Uneasiness Test (BUT), and the Body Attitude Test (BAT), all self-reported measures of one’s perceptions of body size, body uneasiness through body psychopathology questions, and feelings about one’s own body, respectively. Higher scores on all three scales showed greater dissatisfaction and unease with one’s body. The degree of alexithymia in each patient was, as in the Hayaki study, measured using the Toronto Alexithymia Scale. Results of the study showed that 40 of the patients (39.6%) suffered from alexithymia through their scoring of sixty-one or higher on the Toronto Alexithymia Scale. As the survey participants were already suffering from bulimia nervosa or binge-eating disorder, the correlation between alexithymia and bulimia nervosa is again underscored. Indeed, just under half of the one hundred and one study participants were diagnosed with alexithymia. Those diagnosed with alexithymia evidenced in their higher scores on the BSQ-S, BUT, and BAT regarding body image that they also suffered from greater body concerns, body size issues, and lower self-esteem than those not diagnosed with alexithymia. This suggests that the severity of bulimia nervosa may be greater in those suffering from both bulimia and alexithymia. Both the studies of Carano and Hayaki support theories that individuals with emotion dysregulation problems in the form of alexithymia are at greater risk for attaining and maintaining bulimia nervosa. Indeed, one experiencing difficulty distinguishing between emotions and physical sensations through alexithymia could quite easily confuse emotional discomfort with the physical sensation of hunger. This in turn could trigger a food binge, followed by feelings of guilt, fear of weight gain, or merely physical discomfort from over consumption of food, leading to purging or other compensatory behaviors identified with non-purging bulimia. While the studies of Hayaki and Carano found emotion dysregulation in the form of alexithymia a contributing factor to bulimia nervosa, Glauert et al. found media induced body dissatisfaction to be a prominent cause of the disorder as well. Glauert et al. discovered through their study that “Women’s perceptions of body normality and ideal were easily malleable by exposure,” evidencing that media can greatly influence how women feel about their bodies through the images the media decides to expose women to (Glauert, Rhodes, Byrne, Fink, & Grammer, 2008, p. 443). Thus the media can greatly impact the number of women who fall victim to bulimia nervosa. The Glauert et al. study pinpoints that body dissatisfaction is particularly high in Western Societies, where the beauty ideal for women portrayed in magazines, films, etc. is quite uniformly an unhealthfully thin frame unattainable for most women, even through rigorous diet and exercise. Glauert et al. hypothesized that the constant viewing of thin bodies not only altered women’s perceptions of what was beautiful, but also of what was normal. bulimia nervosa, but without behaviors to prevent weight gain, such as self-induced vomiting” (p. 332).

International Journal of Arts and Sciences 3(9): 92 - 101 (2010) CD-ROM. ISSN: 1944-6934 © InternationalJournal.org

This study was performed on 62 Caucasian women from ages 17 to 31. The study participants were asked to complete the Body Shape Questionnaire, which assesses one’s thoughts and feelings about their weight and body shape. The height and weight of the participants were also measured. Next, the participants viewed nineteen “front facing images of computer-generated nude female Caucasian bodies, ranging in BMI [Body Mass Index] from 12 to 30…created in 3d Max” (Glauert et al., 2008, p. 443). Each of the nineteen bodies were presented to the participants ten times, each body for 1000 ms, and the participants were asked to rate the normality of each body (using a keyboard) on a scale of one to nine, with one being too thin, five being normal, and nine being too fat. Next, participants were “randomly assigned to either a ‘thin’ or ‘fat’ condition,” with participants in the “thin” condition presented a body with a BMI of 12 to be viewed for one minute, and participants in the “fat” condition presented a body with a BMI of 30, also to be viewed for one minute (Glauret et al., 2008, p. 445). After the “thin” condition group was exposed to the BMI 12 body and the “fat” condition group exposed to the BMI 30 body, both groups of participants were exposed to the nineteen bodies ranging in BMI from 12-30 that they first viewed and rated. Participants were asked to rate the normality of these bodies a second time. For the “thin” condition group, after first viewing and rating all nineteen bodies ranging in BMI from 12-30, the BMI rated most normal was 18.8. After exposure to the thin BMI 12 body, the “thin” condition group rated a BMI of 16.9 as the most normal when again presented the nineteen bodies with BMI 12-30. The elongated exposure to an extremely thin body decreased the “thin” condition group’s definition of normal body size by 1.9, a difference of nearly two BMI units. The “fat” condition group, after first viewing all nineteen bodies from BMI 12-30, rated a BMI of 19.2 as most normal, a variance of only four hundredths from how the “thin” condition group originally rated the most normal BMI. However, after the “fat” exposure group was exposed to only the BMI 30 body for one minute, when again asked to view all nineteen BMI 12-30 bodies, they raised their opinion of normal BMI from 19.2 to 20.1. This elongated exposure to a body higher on the BMI scale lead the “fat” condition group to increase their definition of normal body size by about one BMI unit. These results evidence that the body size and images one predominantly sees greatly influence what one views as ideal and normal, underscoring the impact the media can have on women through the images they decide to most often present. Indeed, when presented with mostly un-healthfully thin images, women are more likely to prescribe to eating disorders, like bulimia nervosa, in order to achieve the standards the media has set for not only beauty, but also normality. Carano et al.’s study also revealed that: Body dissatisfaction and internalization of the thin Western ideal were related to thinner body ideals…the more a woman internalized Western standards of beauty,

International Journal of Arts and Sciences 3(9): 92 - 101 (2010) CD-ROM. ISSN: 1944-6934 © InternationalJournal.org

and the more dissatisfied she was with her body, the less her perceptions of body ideals were affected by exposure to fat bodies. (Glauert et al., 2008, p. 450) The women in the Carano et al. study whose responses to the Body Shape Questionnaire showed a greater internalization and desire to adhere to the thin Western media ideal of the female body were found to be more at risk for developing bulimia nervosa. Again, the media has great power in affecting the number of women who acquire bulimia nervosa through the unrealistic body type the media predominantly presents. Blechert et al. further support the evidence that development of bulimia nervosa in women can be brought on by media induced body dissatisfaction. According to Blechert, “Numerous studies have investigated the impact of the thin ideal in the mass media on body dissatisfaction…results consistently find a positive correlation between medial exposure and body dissatisfaction” (Blechert, Nickert, Psych, Caffier, Mat, & TushenCaffier, 2009, p. 907). This study sought to assess why only a relatively small percentage of women resort to eating disorders like bulimia nervosa when women the world over are constantly confronted with thin-idealized images in the media. To account for this phenomenon, Blechert et al. presented 20 female bulimia nervosa patients and 22 women not suffering from the disorder with picture slides (on a computer screen) of their own bodies situated between pictures of other bodies with higher and lower BMIs than their own. Each participant’s body was centered between “three comparison bodies with higher BMIs and three comparison bodies with lower BMIs” (Blechert et al, 2009, p. 908). The eye movements of both groups of women were measured when shown these body comparison slides. Results demonstrated that the bulimia patients immediately looked to the thinner bodies being compared to their own rather than the fuller bodies that were also presented on the slide. The bulimia patients also fixated longer on the thinner bodies with low BMIs than did the control group women who were not bulimic. As Blechert et al. (2009) pinpointed: This gaze pattern suggests that upward comparisons were more prevalent in the BN [bulimia nervosa] group…upward comparisons were related to a drop in body satisfaction in the BN group. Disadvantageous social comparison strategies [influenced by bodies promoted by the media] might be related to body dissatisfaction and therefore to the maintenance of BN. (p. 907) Even though the bulimia nervosa patients had the opportunity to compare themselves to images of bodies thicker than their own, these women chose to compare themselves to the thinner bodies. Blechert et al.’s suggestion that body dissatisfied women “make more disadvantageous comparisons by comparing themselves not only with relevant peers but also with professional models, whereas body-satisfied women only compare themselves with peers” seems accurate (Blechert et al., 2009, p. 911). Indeed, for women who are already bulimic, and women prone to making upward body comparisons in general, the excessively thin body image presented almost uniformly by the media works to bring

International Journal of Arts and Sciences 3(9): 92 - 101 (2010) CD-ROM. ISSN: 1944-6934 © InternationalJournal.org

about bulimic behavior and the maintenance of bulimia nervosa in women already suffering from the disorder.

Discussion The results of this literature affirm that emotion dysregulation in the form of alexithymia, making difficult the discrimination between physical sensations and emotions, in addition to media induced body dissatisfaction, are two important contributors to bulimia nervosa among women. Indeed, findings from the respective studies of Hayaki, Carano et al., Glauert et al., and Blechert et al., underscore the validity of this correlation. The studies of Hayaki and Carano et al. support claims regarding the relation of alexithymia to bulimia nervosa, while the studies of Glauert et al. and Blechert et al. support evidence that body dissatisfaction, brought on by deep internalization of media beauty ideals, can lead to the acquiring or maintaining of bulimic behavior in women. The results of this literature review on the causes of bulimia nervosa are important to consider for the prevention of the disorder. Awareness of the dangers unhealthy emotion regulation habits and poor body image pose in relation to bulimia nervosa can guide Western societies in particular—where eating disorders are most prominent—in the areas young women should be educated and guided in. Indeed, if teenage girls were offered programs at school (or in other influential environments) that focused on educating them in healthy emotion regulation and coping mechanisms, in addition to how unrealistic the photo-shopped images presented in films and magazines are, young women would have a better chance at developing and maintaining healthy emotion regulation habits and body image as they mature. This emotional well-being and positive body image will give women the tools they need to successfully battle bulimic tendencies. Furthermore, the results of this literature review are helpful in doctoring effective treatment programs for bulimia nervosa. All of the studies analyzed in this literature review were at least partially performed on women suffering from bulimia nervosa and entailed the asking of many personal questions related to bulimia, body image, and emotion regulation. Therefore, the fact that the answers of these women suffering from bulimia largely showed either or both diagnosis of emotion dysregulation in the form of alexithymia and signs of poor body image is significant: bulimia nervosa treatment programs would undoubtedly prove more effective if the areas of emotional health and body satisfaction were more heavily focused on. Exhorting bulimia patients to analyze their physical hunger and emotion categorization processes, to find emotional comfort in healthy ways not food related, and to accept and appreciate their bodies no matter how different from what the media portrays as beautiful, could help escalate the percentage of permanent bulimia nervosa recoveries. Despite the usefulness and uniformity of results the studies reviewed here provide, the conclusions they draw are not without limitations. Indeed, all four of these studies were performed on limited samples that did not widely range in age of the participants.

International Journal of Arts and Sciences 3(9): 92 - 101 (2010) CD-ROM. ISSN: 1944-6934 © InternationalJournal.org

Though the Carano et al. study was performed only on older adults, Hayaki’s study sampled only undergraduate-aged women, and both Glauert et al. and Blechert et al. also focused solely on young women. It seems studies on bulimia nervosa causes are quite uniformly performed on younger women, though studies such as Carano et al.’s clearly evidence that younger women are not the only women to suffer from the disorder. This is something future studies should attempt to remedy. The study of older women suffering from the disorder would further our knowledge on what causes bulimia to be attained and perhaps more importantly, maintained. It stands to reason that the study of older women suffering from bulimia, who may have acquired the disorder at around age 18 as is often the case, would lead us to conclusions as to why bulimic behaviors are maintained for lifetimes and hopefully help us discover more effective recovery treatments. Another limitation of current studies on contributing factors to bulimia nervosa is the lack of racial diversity in study participants. Most participants in the studies highlighted in this literature review (and studies exploring bulimia nervosa at large) were conducted on Caucasian women. Hayaki’s study sample was 94.8% white, 2.6% Asian, and 2.6% of other ethnicities and races while Glauert et al.’s study consisted entirely of Caucasian women. If future studies were performed on a greater racial demographic, more would be known on bulimia nervosa and if potential causes of the disorder vary along racial lines: though it is helpful to know emotion dysregulation in the form of alexithymia and media induced body dissatisfaction contribute to the risk and acquiring of bulimia in Caucasian women, perhaps other factors are more likely to push women of other races and ethnicities towards bulimic behaviors. Despite limitations posed by current research on the causes of bulimia nervosa among women, the results of this literature review highlight two important factors contributing to the disorder. Women who suffer from emotion dysregulation in the form of alexithymia are at greater risk for developing or maintaining bulimia. Additionally, women who experience body dissatisfaction from comparisons between their own bodies and those spotlighted in the media are also more likely to attain or maintain bulimic behaviors. The results of this literature review also evidence that bulimia nervosa can be prevented and overcome. Through educating girls and women on healthy emotion regulation and promoting positive body image, many girls and women may be prevented from ever developing bulimia. By incorporating these lessons into bulimia nervosa treatment programs, we may also see an increase in lasting recovering rates among those already suffering from the disorder.

International Journal of Arts and Sciences 3(9): 92 - 101 (2010) CD-ROM. ISSN: 1944-6934 © InternationalJournal.org

References Barth, R. (19 September 2008). Bulimia. Retrieved from http://emedicine.medscape.com/article/806548-overview. Blechert, J., Nickert, T., Psych, D., Caffier, D., Mat, D., & Tushen-Caffier, B. (2009). Social Comparison and Its Relation to Body Dissatisfaction in Bulimia Nervosa: Evidence From Eye Movements. Psychosomatic Medicine, 71 (907), 907-912. Bohon, C., Stice, E., & Burton, E. (2008). Maintenance Factors for Persistence of Bulimic Pathology: A Prospective Natural History Study. International Journal of Eating Disorders, 42(2), 173-178. Carano, A., De Berardis, D., Gambi, F., di Paolo, C., Campanella, D., Pelusi, L., Sepede, G., Mancini, E., La Rovere, R., Salini, G., Cotellessa, C., Salerno, R., Ferro, F. (2005). Alexithymia and Body Image in Adult Outpatients with Binge Eating Disorder. International Journal of Eating Disorders, 39(4), 332-340. Doyle, A. C., McLean, C., Washington, B. N., Hoste, R. R., & le Grange, D. (2008). Are Single-Parent Families Different from Two-Parent Families in the Treatment of Adolescent Bulimia Nervosa Using Family-Based Treatment?. International Journal of Eating Disorders, 42(2), 153-157. Glauert, R., Rhodes, G., Byrne, S., Fink, B., & Grammer, K. (2008). Body Dissatisfaction and the Effects of Perceptual Exposure on Body Norms and Ideals. International Journal of Eating Disorders, 42(5), 443-452. Harrison, K. (2003). Television Viewers’ Ideal Body Proportions: The Case of the Curvaceously Thin Woman. Sex Roles, 48(5/6), 255-264. Hayaki, J. (2008). Negative Reinforcement Eating Expectancies, Emotion Dysregulation, and Symptoms of Bulimia Nervosa. International Journal of Eating Disorders, 42(6), 552-556. Langmesser, L., & Verscheure, S. (2009). Are Eating Disorder Prevention Programs Effective?. Journal of Athletic Training, 44(3), 304-305. Thompson, J.K., & Heinberg, L.J. (1999). The Media’s Influence on Body Image Disturbance and Eating disorders: We’ve Reviled Them, Now Can We Rehabilitate Them?. Journal of Social Issues, 55(2), 339-353.