https://doi.org/10.1007/s40519-020-01004-4
ORIGINAL ARTICLE
The association between separation individuation process and binge
eating disorder in adolescents aged 12–18
Ezgi Sen Demirdogen1,2 · Pinar Algedik1,3 · Muhammed Tayyip Kadak1 · Mujgan Alikasifoglu4 ·
Asli Okbay Gunes4 · Turkay Demir1
Received: 23 April 2020 / Accepted: 31 August 2020 © Springer Nature Switzerland AG 2020
Abstract
Purpose To evaluate the associations between separation individuation (SI) process and binge eating disorder (BED) in adolescence aged 12–18 years old, as most challenges related to SI process and eating disorders (EDs) tend to arise in this age group.
Methods This is a cross-sectional study of 30 adolescents diagnosed with BED and 332 healthy adolescents as a control group. All adolescents diagnosed with BED underwent clinical interviews and all adolescents in the study filled in self‐ reported questionnaires.
Results Our results highlighted higher levels of need denial (p = 0.014) and rejection expectancy (p = 0.008) of SI difficulties in adolescents with BED as compared to the ones without BED.
Conclusion This is the first study of its nature providing good evidence for the association between SI process and BED in adolescents. Although these difficulties in SI process by themselves are not evidence of causative link, these results can contribute to the understanding of the causative factors in BED and underpin further research. The correlation can be used as a consideration in the prevention and treatment of BED.
Level of evidence Level III, case-control analytic study.
Keywords Separation individuation · Binge eating disorder · Adolescent
Introduction
EDs are characterized by a series of unhealthy behaviours related to eating, body weight and body shape, where one struggles with selfness and auto-control [1]. EDs cause increased mortality, morbidity and can impair quality of life [2].
Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s4051 9-020-01004 -4) contains supplementary material, which is available to authorized users. * Ezgi Sen Demirdogen
drezgisen@gmail.com Pinar Algedik
pinaralgedik@gmail.com Muhammed Tayyip Kadak tayyibkadak@gmail.com Mujgan Alikasifoglu kasif@istanbul.edu.tr Asli Okbay Gunes asliokbay@gmail.com Turkay Demir
demirturkay@gmail.com
1 Department of Child and Adolescent Psychiatry, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey 2 Department of Child and Adolescent Psychiatry, Sisli
Hamidiye Etfal Training and Research Hospital, 19 Mayis Mah. Etfal Sokak, 34371 Sisli/Istanbul, Turkey
3 Department of Child and Adolescent Psychiatry, Umraniye Training and Research Hospital, Istanbul, Turkey
4 Division of Adolescent Health, Department of Pediatrics, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
BED is the most common ED which is characterized by recurrent binge eating (BE), absence of extreme compen-satory behaviours [3] leading to morbidity and may cause severe, life-threatening conditions with adverse effects on social functioning and quality of life [4, 5]. Although it is considered an adult disorder, recent studies have indicated that BED is quite common in adolescence too and some researchers accept it as the most prevalent ED in youth [6]. The gender difference is not as notable as other EDs, occur-ring two- to four times more frequently in women compared to men, and recent studies suggest similar ratio in adoles-cents [3, 5].
Despite high prevalence of BED, aetiology remains understudied and less understood compared to other EDs [7]. There is, however, an agreement that complex interactions of genetic/biological, psychological and social–environmental factors contribute to disease onset [8, 9]. Some psychosocial factors such as exposure to traumatic life events and poor early life relationships may trigger the development of BED in genetically vulnerable individuals [9, 10]. Association of insecure attachment styles with higher prevalence of EDs further supports this and highlights the importance of under-standing this possible causative process [10, 11]. Psychoana-lytical theories have contributed to understanding the role of risk factors in the development of EDs [12] by focusing particularly on the complex interactions between the child and the caregiver in early formative relationships [13, 14]. One of these theories is separation individuation theory [15].
Separation individuation defines an intrapsychic process of establishment of a sense of self, separated from other primary love objects and the acquisition of one’s unique individuality. Although Separation Individuation Theory of Mahler focuses on the infantile period, many theorists have extended concept of separation individuation to adolescence, with the idea that other critical developmental periods may also contribute to this developmental milestone [16, 17]. Blos, defined it as the “second separation individuation” pro-cess in adolescence. The child in both phases experiences this difficult crisis of gradually moving away from psycho-logical dependence on parents while trying to maintain a sense of connectedness with them. Separation individuation thus deals with the resolution of this ambivalence [18–20]. Any unresolved conflicts of infantile separation individua-tion can be reactivated during adolescence and disturbances in both of the separation individuation processes may lead to a problem of coping with the task of becoming independent or staying connected in relationships [16, 17]. Adolescents who fail to deal adequately with this developmental task of separation individuation are thought to become vulner-able to psychopathology. Abandonment of the idealization of parental figures or dissolving bonds with them causes a sense of emptiness accompanied by a painful alienation and object (mother) hunger. This can then manifest in different
pathological forms like depression, anxiety [16, 17, 21–23] or via dysfunctional eating behaviours to maintain the indi-vidual’s well-being; to fulfil their constant physical and emotional proximity needs [23–25]. BE may thus serve as a regulative function for negative emotions such as anxiety, which may be stemming from a disturbed separation indi-viduation process [24–27].
Although many other family functions were studied in the context of ED, separation individuation theory has been scrutinized in very few studies, which focused on AN and BN only and in adult populations [28–30]. Thus, leaving a crucial gap in the relationship between separation individu-ation process and BED particularly in adolescence; an age where most challenges related to separation individuation process and EDs tend to arise. Considering these, the present study aims to add to this limited body of literature on asso-ciations between the separation individuation process and BED. We specifically hypothesize that separation individu-alization difficulties would be more frequent in adolescents with BED than in adolescents without BED and they would be positively associated with higher levels of maladaptive BE related attitudes/behaviours. In addition, we considered the possibility that a subtype of separation individualization difficulties might be associated with a particular subtype of disordered eating behaviors.
Methods
Participants and procedures
A cross-sectional design is used in this study. Participants were selected from Istanbul Cerrahpasa Medical Collage adolescent division of pediatric outpatients’ unit. Research-ers gave information about the study aims to the pediatri-cians who then gave this information to adolescents who had presented to the clinics with excessive eating and/or weight problems. A total of 88 adolescents and their parents who volunteered were then invited to participate in the study. Oh these 88 adolescents, 30 were diagnosed with BED and included in the study. BED was diagnosed by a child and adolescent psychiatrist (CAP) using DSM-5 diagnostic crite-ria. The diagnosis was confirmed by another CAP to reduce the misclassification bias. Adolescents who were diagnosed with other EDs were excluded because the focus was on BED. We also excluded the adolescents with intellectual disability, autism spectrum disorder, schizophrenia spectrum and other psychotic disorders as their mental state could have affected their ability to complete the questionnaires.
The control group was formed by recruiting volunteers from six schools in various districts of Istanbul (representing low, medium and high sociodemographic levels). Out of the questionnaires given to these 503 adolescents, we excluded
the incomplete questionnaires and the data from the final analysis (n = 38). We did gender matching by first calculat-ing the ratio between boys and girls in the BED group and then excluded randomly selected girls from the control group to match the ratio (n = 133). 332 adolescents were included in the study as the control group. All the adolescents tak-ing part in the study and their parents had given informed consent to take part in the study.
Measures
Sociodemographic data and medical data for the participants were obtained from a questionnaire developed for this study.
Separation individuation test for adolescents (SITA)
Separation individuation test for adolescents (SITA) is a Likert type self-assessment scale designed to measure key dimensions of adolescents’ separation individuation [17]. It has nine subscales measuring separation anxiety, engulf-ment anxiety, nurturance seeking, peer enmeshengulf-ment, teacher enmeshment, practice-mirroring, need denial, rejection expectancy and healthy separation. We used the Turkish version of SITA which was shown to be reliable and a valid measure for Turkish adolescent age group. Turkish SITA has only eight subscales, as healthy separation was not found effective in validity and reliability [30]. The Cronbach alpha values of subscales were 0.67 for Engulfment Anxiety; 0.85 for Practicing Mirroring; 0.63 for Dependency Denial; 0.61 for Separation Anxiety; 0.62 for Teacher Enmeshment; 0.90 for Peer Enmeshment; 0.58 for Nurturance Seeking; 0.81 for Rejection Expectancy.
Eating disorder examination questionnaire—EDE‑Q
Eating disorder examination questionnaire—EDE-Q, reflects the severity of psychopathology consisting of four subscales such as restrictions, eating concerns, body shape concerns and weight concerns [31]. Turkish version of EDE‐Q was shown as a reliable and valid measure for adolescents [32]. The Cronbach alpha values of each subscale were 0.70 and above and 0.93 for whole scale.
Dutch eating behaviour questionnaire—DEBQ
Dutch eating behaviour questionnaire-DEBQ identifies other factors affecting eating behaviour consisting of three sub-scales that measure emotional eating, external eating and restricted eating [33]. Turkish adaptation study showed that Turkish version of DEBQ was a reliable and a valid measure [34]. The Cronbach alpha values of subscales were 0.91 for restrictive eating, 0.90 for external eating, 0.97 for emotional eating and 0.94 for whole scale.
Statistical analysis
Analyses were conducted using STATA version 16. The compliance of the data with the normal distribution was evaluated with the Kolmogorov–Smirnov (K–S) test. The Chi-square (χ2) or Fisher test was used in categorical
variables.
Comparison of separation individuation difficulties and maladaptive eating-related attitudes/behaviours between case and control group was conducted using the Mann–Whit-ney U test as they were numerical variables. Correlation coefficients between the scale scores were analysed using Pearson product moment correlation test (PPMC).
Hierarchical logistic regression (HLR) model was used to establish a robust association between BED and sepa-ration individuation variables. HLR analyses were con-ducted to understand the relationship between BED and variables which were significant between the two groups [rejection expectancy, need denial (p < 0.001)]. The number of siblings, birth order and income were included as soci-odemographic control variables, whereas ages and educa-tion levels of parents were not included. They were highly correlated with the age of the subject and income, respec-tively, and, therefore, could lead to biased estimates due to multicollinearity.
We also ran several linear regressions (LRs) to establish a robust association between maladaptive eating-related attitudes/behaviours and separation individuation variables using EDE-Q and DEBQ scores as dependent (left-hand side) variables and rejection expectancy, need denial as explanatory variables on the right-hand side. In all regres-sions, we report the robust standard errors and associated p-values originating from the t-tests.
The values of less than 0.05 were regarded as statistically significant and exact p-values were reported to indicate the level of significance in the findings.
Results
In our study, mean age (14.77 ± 1.33; 14.97 ± 1.68 years old;
p = 0.534) and gender distribution (13 girls; 17 boys; 149
girls; 184 boys; χ2 = 0.027; p = 0.689) for the respective case
and control groups were not significantly different. There was no significant difference between groups according to sociodemographic variables except educational level of the mothers (p = 0.018). Chronic diseases and the BMI were statistically higher in the case group (p < 0.001) (Table 1). The median BMI of the adolescents with and without BED was 31.66 ± 4.43 kg/m2; 20.34 ± 3.06 kg/m2 and the median
BMI Z scores was 2.42 ± 0.66; − 0.36 ± 1.13, respectively. With regard to the separation individuation process, need denial (p = 0.014) and rejection expectancy (p = 0.008) were
statistically higher in the case group than control group. However, no statistically significant differences were found in a comparison of two groups in terms of other subscale scores (Table 2).
In comparison of both groups according to EDE-Q, all subscales and the total scores were found to be significantly higher in the case group (p < 0.001). In the control group of DEBQ subscale scores, restrictive and emotional eating were significantly higher in the case group (p = 0.005; p = 0.001, respectively), but not in external eating (Table 3).
In Online Resources 2 and 3, we report the results of the HLRs. In all the regressions, the dependent (left-hand side) variable is a dummy variable, which takes the value of 1 if the subject suffers from BED and 0 if the subject
does not. In this regard, each table presents four regres-sions in total. In addition to reporting the benchmark regression first with only the corresponding psychiatric measure as the independent (right-hand side) variable, in the remaining regressions, we add different variables one by one. We do this to see and confirm whether the signifi-cant positive correlation between the relevant psychiatric measure and BED is robust to the inclusion of several dif-ferent control variables. As it is evident from the tables, our results are highly robust, that is, in all the logistic regressions, rejection expectancy and need denial are sig-nificantly associated with a higher tendency to have BED. Next, in Online Resources 4 and 5, we report the results of the LRs. In all the regressions, the dependent (left-hand side) variable is a psychopathological measure and the right-hand side variable is either need denial or rejec-tion expectancy. In this regard, each table presents eight regressions in total. Linear regressions on need denial established that need denial is significantly associated with EDE-Q eating concerns (p = 0.005), EDE-Q shape concerns (p = 0.004), EDE-Q weight concerns (p = 0.002), EDE-Q total (p = 0.006) but not with EDE-Q restriction (p = 0.234) and DEBQ restrained eating (p = 0.411), DEBQ emotional eating (p = 0.14) and DEBQ external eating (p = 0.295). Linear regressions on rejection expec-tancy established that rejection expecexpec-tancy is significantly associated with EDE-Q (p < 0.0001 for all subscales and total scores) and DEBQ scores [restrained eating (p = 0.0017), emotional eating (p < 0.001) and external eating (p = 0.029)].
Table 1 Comparison of sociodemographic variables
TL Turkish Lira *p < 0.05 BED (n = 30) Control (n = 332) p Mean SD Mean SD Age (years) 14.76 1.33 14.9 1.67 0.665 Weight (kg) 90.58 18.87 56.53 11.73 < 0.001 Height (cm) 168.53 11.26 166.13 10.17 0.21 BMI 31.66 4.43 20.34 3.06 < 0.001
Mother age (years) 40.86 5.75 41.47 5.35 0.35 Father age (years) 45.96 5.75 45.39 5.72 0.594 Mother education (years) 8.21 3.55 10.03 4.03 0.018 * Father education (years) 9.57 3.93 10.58 3.77 0.186 Number of sibling 2.33 1.06 2.24 0.97 0.679 Birth order 1.76 0.97 1.65 0.92 0.505 income (TL) 2468.96 1727.11 5373.67 5466.18 0.002*
Table 2 Comparison of the separation–individuation test of
adoles-cence (SITA) scale scores
Mann–Whitney U test *p < 0.05 BED (n = 30) Control (n = 332) p Mean SD Mean SD Separation anxiety 22.57 5.62 22.14 6.33 0.754 Engulfment anxiety 20.7 7.12 20.41 6.18 0.999 Peer enmeshment 29.73 6.09 30.88 5.55 0.300 Teacher enmeshment 18.37 5.72 19.65 5.71 0.218 Practicing-mirroring 42.1 9.76 44.77 11.64 0.271 Need denial 11.77 4.48 9.78 3.63 0.014* Rejection expectancy 36.37 11.73 30.14 8.65 0.008* Nurturance seeking 26.23 5.06 26.94 5.54 0.520
Table 3 Comparison of EDE-Q and DEBQ scale scores
Mann–Whitney U test
EDE-Q Eating Disorder Evaluation Questionnaire, DEBQ Dutch eat-ing behaviour questionnaire
**p < 0.001, *p < 0.05 BED (n = 30) Control (n = 332) p Mean SD Mean SD EDE-Q Scores Restraint 1.84 1.29 1.13 1.54 < 0.001 Eating concerns 2.43 1.2 0.85 1.13 < 0.001 Shape concerns 4.15 1.3 1.64 1.68 < 0.001 Weight concerns 3.7 1.47 1.45 1.55 < 0.001 Total 3.03 1.08 1.27 1.33 < 0.001 DEBQ Scores Restrained eating 24.43 7.13 20.32 9.45 0.005* Emotional eating 38.8 19.05 26.43 16.22 0.001* External eating 31.13 9.77 29.08 9.71 0.336
Discussion
In our study, the results highlighted some common features in the separation individuation process of BED patients, although difficulties in the separation individuation pro-cess by themselves are not evidence of causative link, as all psychopathology is multidetermined and other features of the family and the individual’s personal history may play a role [35–37].
In our study, adolescents with BED had difficulties with need denial. HLR showed that there was significant posi-tive association between need denial and BED presence. In a previous study of 202 twin adolescents, need denial was found to be a strong determinant for BE behaviour in AN and BN [17]. Adolescents with BED may feel strongly threatened by the developmental demands of separation individuation and may try to deny emotional need from others and balance these strong emotional urges with food-BE [38]. They may feel insecure about the availability of attachment figures so they may try to use food to cope with perceived absence. They may not accept the loss of control in their disturbed relationships with attachment figures and may use food as a replacement instead of her/ his emotions hence maintaining need denial from others. [39, 40]. The individual can act out almost every aspect of the ambivalent struggle with the actual and the inter-nalized mother through control of food intake; it can be a way of both demanding and rejecting nurturance and defying the mother through being in absolute control. The maternal object may be accessed through the bingeing thus replicating the conflict with the mother [36, 37, 39]. The experience of the separation individuation process may be symbolically replaced with food, which is the most con-crete possible symbol of the maternal object [35].
Similarly, the results highlighted higher levels of the other subtype of separation individuation—rejection expectancy in adolescents with BED. HLR supported our hypothesis that rejection expectancy has a significant positive association with BED. Contrary to the BN, the purging behaviours are not observed in BED, which can be explained by absence of engulfment anxiety and also by the presence of rejection expectancy [17]. Adolescent with BED takes the food (mother) inside by BE but then keeps it inside so that she/he can control it and when the mother (food) is inside and under control there will not be danger of rejection, hence mitigating the rejection expec-tancy [17, 28, 36].
In keeping with the earlier finding the engulfment anxi-ety did not differ within the two groups in our study Egg-ert et al. found that the adolescents with BN symptoms showed higher levels of engulfment anxiety [17] and our study adds to this as the BED group did not have purging
behaviour and did not have engulfment anxiety. Individu-als with engulfment anxiety may be fearful of close inter-personal relationships and perceive others as threat to their sense of independence and selfhood—feeling controlled, overpowered, or enveloped [17, 18]. So, in BN, individu-als first take food (mother) in because of the need (may be a need to get rid of an anxiety) but once food (mother) is swallowed, the anxiety is replaced by engulfment anxiety, anxiety of being swallowed by the mother leading to an immediate compensatory behaviour of purging—throwing out food (mother); purging behaviour may thus be consid-ered a way of getting rid of threatening object represented by food [17, 41–43].
The results from our study about the eating–weight–shape concerns, restrictive eating and emotional eating were also consistent with the current research.
1. Eating–weight–shape concerns Adolescents with BED had higher levels of eating–weight–shape concerns con-sistent with the literature. The presence of overestima-tion of weight and shape has been found to be associated with high levels of BE and a trend indicator in patients with BED. LRs also supported the association between need denial and rejection expectancy with BED indi-rectly by indicating the association between need denial and rejection expectancy with eating, weight, and shape concerns, which have been reported as associated nega-tive emotions with BE and BED in previous studies [44,
45].
2. Restrictive eating, dietary restraint scores were higher in the adolescents with BED in our study consistent with the literature. Dietary restriction interventions were shown to be associated with an increase in BE attacks in individuals with BED and it was found to be an important predictor of BE. LRs, also, supported the association between rejection expectancy with BED indirectly—evidencing the association of rejection expectancy with dietary restriction which was shown to be associated with BE and BED [46, 47]. Need denial did not have an association with dietary restriction and this supported the possible theoretical explanations that adolescents who have need denial, contradictory to restriction, may try to replace their emotional need with food.
3. Our results indicated that emotional eating (a desire to eat in response to emotions) scores were higher in the adolescents with BED consistent with the literature [48,
49]. It is also consistent with our results that emotional eating, higher levels of negative emotions of rejection expectancy was associated with BED and LRs supported this association indirectly, indicating the relationship between rejection expectancy and emotional eating. Need denial, however, did not show an association
with emotional eating which may be self-contradictory because the individuals with need denial will need to first accept the emotions then only be able to associate the emotional and external stimuli for eating. There was no objective way of finding this association due to self-reporting nature of the scales.
In summary, elevated levels of anxiety are produced by struggles of separation individuation process (need denial and rejection expectancy) and the individual may try to ease these anxieties by BE episodes without any purging behav-iour where the BE “may serve a multitude of functions, including the sadistic, destructive control of the needed object, but it also soothes, tranquillizes and alleviates inner rage and tension, depression and loss” [28, 36].
Limitations
The results of this study should be studied bearing in mind the small sample size highlighting the need for future research to be on a larger, more diverse sample with big-ger age ranges and various socioeconomical strata so that any differences partially attributed to these characteristics may be ascertained. Second, the cross-sectional nature of the study does not provide a causal link but signpost to the need for longitudinal studies on this topic to explore any temporal and causal relations with the psychosocial variables.
What is already known on this subject?
The presence of higher levels of psychopathology and etio-logical factors such as disruptions in early formative rela-tionships between the baby and the caregiver, reflection of relational conflict on the body, struggles for autonomy via food intake and body shape are already shown in the EDs literature.
What does this study add?
This is the first study of its nature that provides good evi-dence for the association between separation individuation process and BED in adolescents. A recent meta-analysis of psychological and pharmacological treatments for BED found that psychotherapy and structured self-help treatments had more robust effects on outcomes, including binge absti-nence [50]. In interpersonal treatments, there are various theories used to focus on the problem. Supported by our research, it may be helpful for the therapists to consider breakdowns in separation individuation process as one of the main approaches in the therapy. The data generated in
this study can be used to set up further investigations on the possible causative relationship between separation individu-ation and BED.
Availability of data and material
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Author contributions All authors contributed to the study conception
and design. Material preparation, data collection and analysis were performed by ESD, PA, MTK, MA, AOG, TD. The first draft of the manuscript was written by ESD and all authors commented on previ-ous versions of the manuscript. All authors read and approved the final manuscript.
Funding The authors declared that this study has received no financial support.
Compliance with ethical standards
Conflict of interest The authors have no conflicts of interest to declare. Ethical approval The study protocol was approved by Istanbul
Univer-sity Cerrahpasa Medical Faculty Ethics Committee.
Informed consent Informed consent was obtained from all participants
and their families.
References
1. Levine MP, Piran N, Jasper K (2015) Eating disorders. Handbook of adolescent behavioral problems evidence-based. Springer Sci-ence Business Media, New York
2. Rosen DS (2003) Eating disorders in children and young ado-lescents: etiology, classification, clinical features, and treatment. Adolesc Med Clin 14(1):49
3. Udo T, Grilo CM (2018) Prevalence and correlates of DSM-5— defined eating disorders in a nationally representative sample of US adults. Biol Psychiat 84(5):345–354. https ://doi.org/10.1016/j. biops ych.2018.03.014
4. Hay P (2003) Quality of life and bulimic eating disorder behav-iors: findings from a community-based sample. Int J Eat Disord 33(4):434–442. https ://doi.org/10.1002/eat.10162
5. Welch E, Jangmo A, Thornton LM, Norring C, von Hausswolff-Juhlin Y, Herman BK, Bulik CM (2016) Treatment-seeking patients with binge-eating disorder in the Swedish national regis-ters: clinical course and psychiatric comorbidity. BMC Psychiatry 16(1):163. https ://doi.org/10.1186/s1288 8-016-0840-7
6. Dakanalis A, Zanetti MA, Colmegna F, Riva G, Clerici M (2018) Classifying binge eating-disordered adolescents based on severity levels. J Adolesc 62:47–54. https ://doi.org/10.1016/j.adole scenc e.2017.10.003
7. Kessler RM, Hutson PH, Herman BK, Potenza MN (2016) The neurobiological basis of binge-eating disorder. Neurosci Biobehav Rev 63:223–238. https ://doi.org/10.1016/j.neubi orev.2016.01.013
8. Bakalar JL, Shank LM, Vannucci A, Radin RM, Tanofsky-Kraff M (2015) Recent advances in developmental and risk factor research on eating disorders. Current Psychiatry Rep 17(6):42. https ://doi.org/10.1007/s1192 0-015-0585-x
9. Pike KM, Wilfley D, Hilbert A, Fairburn CG, Dohm FA, Striegel-Moore RH (2006) Antecedent life events of binge-eating disorder. Psychiatry Res 142(1):19–29. https ://doi. org/10.1016/j.psych res.2005.10.006
10. Tasca GA, Balfour L (2014) Attachment and eating disorders: a review of current research. Int J Eat Disord 47(7):710–717. https ://doi.org/10.1002/eat.22302
11. Kullman A (2007) The “perseverant” personality: a preattach-ment perspective on the etiology and evolution of binge/purge eating disorders. Psychoanal Dialogues 17(5):705–732. https :// doi.org/10.1080/10481 88070 16325 09
12. Granieri A, Schimmenti A (2014) Mind–body splitting and eating disorders: a psychoanalytic perspective. Psychoa-nal Psychother 28(1):52–70. https ://doi.org/10.1080/02668 734.2013.87217 2
13. Lerner HD (1983) Contemporary psychoanalytic perspectives on gorge-vomiting. A case illustration. Int J Eat Disord 3(1):47–63. https ://doi.org/10.1002/1098-108X(19832 3)3:1%3C47:AID-EAT22 60030 105%3E3.0.CO;2-K
14. Jeammet P, Chabert C (1998) A psychoanalytic approach to eating disorders: the role of dependency. Adolesc Psychiatry 22:59 15. Friedlander ML, Siegel SM (1990) Separation-individuation
dif-ficulties and cognitive-behavioral indicators of eating disorders among college women. J Couns Psychol 37(1):74. https ://psycn et.apa.org/doi/10.1037/0022-0167.37.1.74
16. Mahler MS, Pine F, Bergman A (1975) The Psychological Birth of the Human Infant. Symbiosis and Individuation. New York (Basic Books)
17. Eggert JW (2007) Separation-individuation and Disordered Eat-ing in Adolescence. Michigan State University. Department of Psychology https ://doi.org/10.25335 /M5JD4 Q47J
18. Levine JB, Green CJ, Millon T (1986) The separation-individua-tion test of adolescence. J Pers Assess 50(1):123–139. https ://doi. org/10.1207/s1532 7752j pa500 1_14
19. Blos P (1967) The second individuation process of adoles-cence. Psychoanal Study Child 22(1):162–186. https ://doi. org/10.1080/00797 308.1967.11822 595
20. Wichman RE (1997) The relationship between family structure, parent-child separation-individuation, and eating disorders in ado-lescent females. Doctoral dissertation, The Ohio State University 21. Kins E, Beyers W, Soenens B (2013) When the separation-individ-uation process goes awry: distinguishing between dysfunctional dependence and dysfunctional independence. Int J Behav Dev 37(1):1–12. https ://doi.org/10.1177/01650 25412 45402 7 22. Kins E, Soenens B, Beyers W (2012) Parental psychological
control and dysfunctional separation–individuation: a tale of two different dynamics. J Adolesc 35(5):1099–1109. https ://doi. org/10.1016/j.adole scenc e.2012.02.017
23. Quintana SM, Kerr J (1993) Relational needs in late adolescent separation-lndividuation. J Couns Dev 71(3):349–354. https ://doi. org/10.1002/j.1556-6676.1993.tb022 25.x
24. Friedlander ML, Siegel SM (1990) Separation-individuation dif-ficulties and cognitive-behavioral indicators of eating disorders among college women. J Couns Psychol 37(1):74. https ://psycn et.apa.org/doi/10.1037/0022-0167.37.1.74. Accessed 22 Jan 2020 25. Rhodes B, Kroger J (1992) Parental bonding and separation-individuation difficulties among late adolescent eating disordered women. Child Psychiatry Hum Dev 22(4):249–263. https ://doi. org/10.1007/BF007 07667
26. Barth FD (2003) Separate but not alone: separation-individuation issues in college students with eating disorders. Clin Soc Work J 31(2):139–153. https ://doi.org/10.1023/A:10229 10327 003
27. Leehr EJ, Krohmer K, Schag K, Dresler T, Zipfel S, Giel KE (2015) Emotion regulation model in binge eating disorder and obesity—a systematic review. Neurosci Biobehav Rev 49:125– 134. https ://doi.org/10.1016/j.neubi orev.2014.12.008
28. Armstrong JG, Roth DM (1989) Attachment and separation dif-ficulties in eating disorders: a preliminary investigation. Int J Eat Disord 8(2):141–155. https ://doi.org/10.1002/1098-108X(19890 3)8:2%3C141 :AID-EAT22 60080 203%3E3.0.CO;2-E
29. Holtom-Viesel A, Allan S (2014) A systematic review of the lit-erature on family functioning across all eating disorder diagnoses in comparison to control families. Clin Psychol Rev 34(1):29–43. https ://doi.org/10.1016/j.cpr.2013.10.005
30. Bildik T, Tamar M, Dural S, Şen Kösem F, Yücel İnan G, Yaman B, Korkmaz Çetin S, Özbaran B, Erermiş S, Aydın C (2010) Ado-lesan ayrılma bireyleşme testi: Geçerlilik ve Güvenirlik Çalışması 20. Ulusal Çocuk ve Ergen Ruh Sağlığı ve Hastalıkları Kongresi Özet Kitabı, 162, Doctoral dissertation
31. Fairburn CG, Beglin SJ (1994) Assessment of eating disorders: Interview or self-report questionnaire? Int J Eat Disord 16(4):363– 370. https ://doi.org/10.1002/10981 08X(19941 2)16:4%3C363 :AIDEA T2260 16040 5%3E3.0.CO;2-#
32. Yucel B, Polat A, Ikiz T, Dusgor BP, Elif Yavuz A, Sertel Berk O (2011) The Turkish version of the Eating Disorder Examina-tion QuesExamina-tionnaire: reliability and validity in adolescents. Eur Eat Disord Rev 19(6):509–511. https ://doi.org/10.1002/erv.1104 33. Van Strien T, Frijters JE, Bergers GP, Defares PB (1986) The
Dutch Eating Behavior Questionnaire (DEBQ) for assessment of restrained, emotional, and external eating behavior. Int J Eat Disord 5(2):295–315. https ://doi.org/10.1002/1098-108X(19860 2)5:2%3C295 :AID-EAT22 60050 209%3E3.0.CO;2-T
34. Bozan N (2009) Hollanda yeme davranışı (DEBQ) anketinin Türk üniversite öğrencilerinde geçerlilik ve güvenirliğinin sınanması. Doctoral dissertation
35. Kramer S, Akhtar S (1988) The developmental context of internal-ized preoedipal object relations: clinical applications of Mahler’s theory of symbiosis and separation-individuation. Psychoanal Q 57(4):547–576. https ://doi.org/10.1080/21674 086.1988.11927 221 36. Beattie HJ (1988) Eating disorders and the mother–daugh-ter relationship. Int J Eat Disord 7(4):453–460. https ://doi. org/10.1002/1098-108X(19880 7)7:4%3C453 :AID-EAT22 60070 402%3E3.0.CO;2-2
37. Caparrotta L, Ghaffari K (2006) A historical overview of the psychodynamic contributions to the understanding of eating disorders. Psychoanal Psychother 20(3):175–196. https ://doi. org/10.1080/02668 73060 08688 07
38. Mikulincer M, Shaver PR, Pereg D (2003) Attachment theory and affect regulation: The dynamics, development, and cogni-tive consequences of attachment-related strategies. Motiv Emot 27(2):77–102. https ://doi.org/10.1023/A:10245 15519 160 39. Patton CJ (1992) Fear of abandonment and binge eating: a
sub-liminal psychodynamic activation investigation. J Nerv Mental Dis https ://psycn et.apa.org/doi/10.1097/00005 053-19920 8000-00002 . Accessed 22 Jan 2020
40. Gander M, Sevecke K, Buchheim A (2015) Eating disorders in adolescence: attachment issues from a developmental perspective. Front Psychol 6:1136. https ://doi.org/10.3389/Ffpsy g.2015.01136 41. Garner DM, Rosen LW (1990) Anorexia nervosa and bulimia
nervosa. In: International handbook of behavior modifica-tion and therapy. Springer, Boston, pp. 805–817. https ://doi. org/10.1007/978-1-4613-0523-1_37
42. Krause ED, Robins CI, Lynch TR (2000) A mediational model relating sociotropy, ambivalence over emotional expression, and disordered eating. Psychol Women Q 24(4):328–335. https ://doi. org/10.1111/j.1471-6402.2000.tb002 15.x
43. Savelle-Rocklin N (2016) Food for thought: perspectives on eating disorders. Rowman & Littlefield, Lanham
44. Mond JM, Hay PJ, Rodgers B, Owen C (2007) Recurrent binge eating with and without the “undue influence of weight or shape on self-evaluation”: implications for the diagnosis of binge eating disorder. Behav Res Ther 45(5):929–938. https ://doi. org/10.1016/j.brat.2006.08.011
45. Hrabosky JI, Masheb RM, White MA, Grilo CM (2007) Overvalu-ation of shape and weight in binge eating disorder. J Consult Clin Psychol 75(1):175. https ://doi.org/10.1037/0022-006X.75.1.175 46. Elran-Barak R, Sztainer M, Goldschmidt AB, Crow SJ, Peterson
CB, Hill LL, Le Grange D (2015) Dietary restriction behaviors and binge eating in anorexia nervosa, bulimia nervosa and binge eating disorder: trans-diagnostic examination of the restraint model. Eat Behav 18:192–196. https ://doi.org/10.1016/j.eatbe h.2015.05.012
47. Stein RI, Kenardy J, Wiseman CV, Dounchis JZ, Arnow BA, Wil-fley DE (2007) What’s driving the binge in binge eating disorder? A prospective examination of precursors and consequences. Int J Eat Disord 40(3):195–203. https ://doi.org/10.1002/eat.20352
48. Pinaquy S, Chabrol H, Simon C, Louvet JP, Barbe P (2003) Emotional eating, alexithymia, and binge-eating disorder in obese women. Obes Res 11(2):195–201. https ://doi.org/10.1038/ oby.2003.31
49. Masheb RM, Grilo CM (2006) Emotional overeating and its asso-ciations with eating disorder psychopathology among overweight patients with binge eating disorder. Int J Eat Disord 39(2):141– 146. https ://doi.org/10.1002/eat.20221
50. Iacovino JM, Gredysa DM, Altman M, Wilfley DE (2012) Psy-chological treatments for binge eating disorder. Curr Psychiatry Rep 14(4):432–446. https ://doi.org/10.1007/s1192 0-012-0277-8
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