For Peer Review

THE EATING-RELATED INTRUSIVE THOUGHTS INVENTORY:

EXPLORING THE DIMENSIONALITY OF EATING DISORDER

SYMPTOMS

Journal: Clinical Psychology & Psychotherapy

Manuscript ID: CPP-0246.R1

Wiley - Manuscript type: Assessment

Date Submitted by the Author:

n/a

Complete List of Authors: Perpiñá, Conxa; University of Valencia; Ciber Fisiopatología Obesidad y Nutrición (CIBERON),, Instituto de Salud Carlos III Roncero, María; University of Valencia Belloch, Amparo; University of Valencia Sánchez-Reales, Sergio; University of Valencia

Keywords: intrusive thoughts, eating disorders, dysfunctional appraisals, thought-control strategies, self-assessment

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TITLE:

THE EATING-RELATED INTRUSIVE THOUGHTS INVENTORY: EXPLORING

THE DIMENSIONALITY OF EATING DISORDER SYMPTOMS

AUTHORS AND AFFILIATIONS:

Conxa Perpiñá1,2

, María Roncero2, Amparo Belloch

2, and Sergio Sánchez-Reales

2.

1Ciber Fisiopatología Obesidad y Nutrición (CIBERON), Instituto de Salud Carlos III

(Spain).

2 Department of Personality Psychology. Research Unit for Obsessive-Compulsive and

Eating Disorders. Facultad de Psicología. University of Valencia (Valencia, Spain).

CORRESPONDING AUTHOR:

Prof. Conxa Perpiñá, Ph.D.

Dpto. Personalidad, Evaluación y Tratamientos Psicológicos.

Facultad de Psicología. Universidad de Valencia

Av. Blasco Ibañez, 21. 46010, Valencia. (Spain)

E-mail: perpinya@uv.es.

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ABSTRACT

Objective: The main purpose of the present study was to explore the

existence of a continuum ranging from normal to abnormal unwanted mental

intrusions related to eating, weight and shape. This general purpose was divided

into two objectives: first, to examine the factorial structure by means of

Confirmatory Factorial Analysis (CFA) and psychometric properties of the INPIAS

(Eating Intrusive Thoughts Inventory); and second, to explore the dimensionality

of EDITs(Eating Disorder Intrusive Thoughts), and the frequency with which they

are experienced by low and high dietary restraint individuals. Method: 574

participants (491 Low Dietary Restraint, LDR; 83 High Dietary Restraint, HDR

groups) were administered the INPIAS and other related measures. Results: The

CFA revealed that these intrusive cognitions may be clustered into three different

groups: EDITs about physical appearance and dieting, EDITs about the need to do

exercise, and finally those related to thoughts and impulses typically reported by

people suffering from ED. Analysis of the consequences showed a two-factor

structure composed of Emotional consequences and personal meaning and Thought

Action Fusion and responsibility, and four factors of strategies: “anxious”,

suppression, OC-rituals and distraction. Differences between HDR and LDR were

found in the frequency with which participants experienced EDITs, whereas

differences in the other factors were mediated by depression, anxiety, and

obsessionality. Conclusions: the INPIAS is a reliable and valid instrument to

evaluate EDITs in nonclinical samples. The results suggest that ED cognitions are

at one end of a continuum of unwanted cognitive intrusions that are also

experienced by nonclinical people.

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Key Practitioner Message

* The INPIAS is a self-report of intrusive-related eating thoughts useful to asses these

mental phenomenon in general population.

*It is a self report easy to administer with strong psychometric properties.

*It is useful in detecting vulnerable people with disordered eating with problems in the

emotional consequences and the dysfunctional strategies to cope with this kind of

intrusions.

Keywords: intrusive thoughts; eating disorders; dysfunctional appraisals; thought-

control strategies, self-assessment.

.

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THE EATING-RELATED INTRUSIVE THOUGHTS INVENTORY:

EXPLORING THE DIMENSIONALITY OF EATING DISORDER SYMPTOMS

Unwanted intrusive thoughts, images, or impulses (UIT) play a significant role

in the onset and maintenance of several clinical conditions, such as depression (negative

automatic thoughts), generalized anxiety disorder (worry), obsessive-compulsive

disorder, psychosis, post-traumatic stress disorder, sexual offenders, and insomnia

(Rachman, 1981; Sarason, Pierce, & Sarason, 1996). Clark and Rhyno (2005) have

defined the clinically relevant unwanted intrusive thoughts as “any distinct, identifiable

cognitive event that is unwanted, unintended, and recurrent. It interrupts the flow of

thought, interferes in task performance, is associated with negative affect, and is

difficult to control” (page 4).

Apart from the psychopathological relevance of the UIT, the empirical research

has also clearly shown that nonclinical individuals also experience unwanted mental

intrusions that are similar in form and content to the clinically relevant UIT (Purdon &

Clark, 1993; 1994). From this research, clinical symptoms like obsessions, ruminations,

or automatic thoughts, among others, can be considered as the pathological end of

normal UIT, which implies taking a dimensional view of these symptoms.

Regarding the Eating Disorders (ED), only three studies have examined the

clinically relevant intrusive thoughts, images, or impulses related to ED contents, that

is, intrusions about food, weight, shape, exercise, dieting, purging, vomiting, and so on

–henceforth referred to as eating disorder related intrusive thoughts (EDITs). Clark,

Feldman, and Channon (1989) administered the Modified Distressing Thoughts

Questionnaire to Anorexia Nervosa and Bulimia Nervosa patients. This self-report

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evaluates negative cognitions related to depression and anxiety, as well as weight-

related thoughts. More recently, Verplanken and Velsvik (2008) administered the Habit

Index of Negative Thinking to adolescents from the general population. This

questionnaire assesses the frequency and automaticity of the occurrence of body image

dissatisfaction thoughts. Although the two above-mentioned studies are not specifically

focused on UIT, their results suggest that both ED patients and non-clinical adolescents

experience upsetting thoughts about food, figure and weight, as well as purging and

fasting impulses. Finally, Perpiñá, Roncero, and Belloch (2008) designed a specific self-

administered questionnaire, Inventario de Pensamientos Intrusos Alimentarios (Eating-

related intrusive thoughts Inventory), INPIAS, to assess the frequency with which non-

clinical subjects experience EDITs. The inventory follows the structure of the Revised-

Obsessional Intrusions Inventory (ROII; Purdon & Clark, 1993; Purdon & Clark, 1994),

and has two parts. In the first one, subjects must indicate the frequency with which they

experience each of a list of 50 EDITs. In the second part, subjects are required to select

from the previous list the single most upsetting intrusive thought that they have

experienced at least “rarely”. Then, the respondent must evaluate, first, the emotional

impact, interference, and evaluative appraisals of this most upsetting EDIT, and second,

the strategies used to keep it under control. The great majority of participants were

university students, who reported having some of the 50 EDITs at least once in the last

three months. The most frequently experienced EDITs were those related to doing

exercise, whereas intrusions like the need to vomit or take laxatives were reported less

frequently. A principal components factor analysis indicated a two-factorial structure

for the first part of the INPIAS: the first one included EDITs like, “I need to go on a

diet”, or “I am fat”; and the second one grouped EDITs related to disordered eating and

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impulses (i.e., “Should I vomit?)”. Regarding the INPIAS’ second part, the emotional

impact, interference, and evaluative appraisals were clustered into two broad factors:

Emotional consequences and Personal significance of the intrusion. The

control/neutralizing strategies were grouped into four factors: self-reassurance,

suppressing and/or neutralizing, obsessive-compulsive related rituals, and no-resistance

to the EDIT.

These findings provide initial evidence that non clinical individuals experience

UIT whose contents are related to typical eating concerns, and they suggest that the

INPIAS could be useful to assess EDITs in non clinical populations. However, as far as

we know, there are no studies specifically designed to examine the extent to which the

EDITs can be considered as the normal end of clinically relevant UIT with eating

disorder contents. The main purpose of the current study was to explore the existence of

a continuum ranging from normal to abnormal ED related intrusive thoughts.

To that end, we first examined the factorial structure and psychometric properties

of the INPIAS, the only self-report specifically designed to assess EDITs, as far as we

know. Second, in order to explore the dimensionality of EDITs, we examined the

frequency with which they are experienced by low and high dietary restrainer

individuals, taking into account that restraint is usually considered a risk factor for the

development of ED.

These objectives could be operationalized as a set of exploratory hypotheses.

Regarding the first objective, we expect that: a) The initial factorial structure of INPIAS

will be confirmed in a large non-clinical community sample; and b) INPIAS will be

more associated with ED measures than with general distress indexes (depression,

anxiety, and worry proneness). With regard to the second objective, we expect that high

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dietary restrainers, compared with low, will obtain higher scores on the various INPIAS

derived subscales.

METHOD

Participants

The participants were 574 subjects (408 women) from the community. Their

mean age was 24.90 (SD = 6.10) years (range= 14 to 46 years). The majority of the

subjects were single (81.4%), identified themselves as having a medium socio-

economic level (68.8%), and had university level studies (62.2%). Prior to participating

in the study, the subjects were individually asked if they were currently suffering any

diagnosed mental disorder, and/or receiving psychological or pharmacological treatment

for some mental problem. Only those subjects who reported neither suffering

psychological disorders nor receiving psychological or psychiatric treatment at the time

of the study were included. Their mean Body Mass Index (BMI) was 22.35 (SD= 3.16;

range= 17.02-32.42). All the individuals gave their explicit consent to participate in the

research.

Instruments

Eating Intrusive Thoughts Inventory (Inventario de Pensamientos Intrusos

Alimentarios, INPIAS) (Perpiñá et al., 2008). This is a self-report questionnaire

designed to assess the presence and frequency of unwanted intrusive thoughts, images

and impulses related to dieting, body appearance, and the need to do exercise, as well as

the appraisals and control strategies associated with the most upsetting eating disorder-

related intrusive thought experienced by the participants. The instrument includes initial

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instructions offering a detailed characterization of the nature of intrusive thoughts. The

INPIAS consists of two parts. The first one includes 50 statements concerning thoughts,

images and impulses about dieting and exercise, as well as appearance and body-image.

The items are clustered under several scenarios (before, during or after eating; looking

at oneself in the mirror; in a social context; or independently of a specific situation).

Each item is rated on a 7-point scale ranging from 0 (“I have never had this thought”)

to 6 (”I have this thought frequently during the day). In the second part, participants are

required to select from the previous list the single most upsetting intrusive thought that

they have experienced at least “rarely” (score=1), and then evaluate it using 5-point

Likert scales (From 0= “Absolutely nothing” to 4= “Extremely”), on sixteen items

designed to record the emotional consequences for having this thought (unpleasantness,

anxiety, sadness, guilt, shame and insecurity), the interference and difficulty of control,

and the appraisals the subject ascribes to the thought (importance of the thought, worry

thought will come true, unacceptability, thought-action fusion likelihood and moral,

importance of control, overestimation of threat, and responsibility). This section of the

questionnaire was called Part-2-A. After completing this section, participants were

presented with a list of 22 possible thought control and/or neutralizing strategies (i.e.

self/others reassurance, cognitive and behavioral distraction, avoidance, suppression),

and they were asked to rate (from 0= “Never” to 4= “Always”) to what extent they use

each of these strategies to deal with the most upsetting intrusive thought previously

chosen. This section of INPIAS is labeled Part-2-B.1

1 A copy of the questionnaire (in Spanish or in English -forward and back translations) is

available upon request from the first author.

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The Restraint Scale (RS; Herman & Polivy, 1980). This self-report assesses

weight fluctuation and subjective concern about dieting. It consists of 10 items on a 4

(nothing/never) or 5 (a lot/always)-point scale. Following Heartherton, Herman, Polivy,

King, and McGree (1988), a score of 16 is a reliable cut-off point between restrainers

and non-restrainers. The internal consistency in the present study for the total score was

.81, and for the Weight fluctuation and Concern about dieting subscales, .77 and .67,

respectively.

Multidimensional Body-Self Relations Questionnaire (MBSRQ; Brown, Cash, &

Mikulka, 1990). This is a 34 item self-report inventory designed to assess self-

attitudinal aspects related to body-image, which must be answered on a 5-point scale

ranging from 1 (totally disagree) to 5 (totally agree). The MBSRQ consists of five

subscales: Appearance evaluation, appearance orientation, body-weight satisfaction,

preoccupation with being overweight, and self-classified weight. In this study, the

internal consistency ranged from α=.85 to α=.79 across the subscales.

The Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, &

Borkovec, 1990), is a 16-item self-report inventory designed to assess the generality,

excessiveness and uncontrollability dimensions of worry. The Spanish version applied

in this study (Sandín, Chorot, Valiente, & Lostao, 2009) has demonstrated good

psychometric properties in a community sample (Cronbach’s α=.83; Mean 45.08, SD=

10.40; percentage of variance explained, one factor = 35.8%).

Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996). This is a 21-item

self-reported measure of the intensity or severity of depressive symptoms, using a 4-

point scale ranging from 0 (Symptom not present) to 3 (Symptom very intense). The

Spanish version (Sanz & Vázquez, 1998) was used, obtaining an internal consistency

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for the present study of .87. The mean (SD) was 11 (5.2), and the scores ranged from 0

to 16.

Beck Anxiety Inventory (BAI; Beck & Steer, 1993). This self-report evaluates

anxiety-related somatic symptoms across 21 items, rated on a 4-point Likert scale from

0 (not at all) to 3 (severely). In the present study, the Cronbach’s α value was .87. The

mean (SD) of the scores in this study was 15.2 (8.12), and the range was from 0 to 23.

Clark-Beck Obsessive Compulsive Inventory (C-BOCI; Clark & Beck, 2002) This

is a self-report instrument that evaluates obsessive-compulsive symptoms across 25

items grouped in two scales (obsessions and compulsions) with a 4-point scale from 0

(never/totally disagree) to 3 (always/totally agree). The Spanish version of this

instrument (Belloch, Reina, García-Soriano, & Clark, 2009) has shown a good internal

consistency in the present study (Total score α=.88; obsessions scale α=.84;

compulsions scale α=.77). The mean (SD) in this study was 12.35 (7.35), and the scores

ranged from 0 to 31.

Procedure

The participants were recruited by a group of students from the two last courses

of the Psychology degree program who received partial course credit for their

collaboration. They were first trained in the use of the instruments in a two-hour

seminar in which the purpose of the study and the measure instruments were explained.

The participants were also trained in the application of the instruments. At the end of

the seminar they were invited to administer the questionnaire packet individually to

three to five relatives or friends, taking into account the following criteria: they could

not be university psychology students; they had to be between 14 and 45 years of age;

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they had to have a good level of reading ability; they could not have a recent history of

mental disorder or be receiving psychological/psychiatric treatments (preceding year);

and they could not obtain scores suggesting depression, anxiety, or obsessive-

compulsive disorder on the clinical measures (BDI, BAI, C-BOCI). In order to limit

order and sequence effects, the measures were arranged in two counterbalanced orders,

and each participant was randomly assigned to receive one of the two orders. Half of the

participants completed INPIAS again between 7 and 15 days later. Ethical approval for

carrying out this study was granted by the University Ethics Committee. Prior to filling

out the questionnaire packet, each person signed an informed assent and consent to

participate in the study.

Statistical analyses

The CFAs were conducted using the EQS 6.10 program for Windows. A logical

comparison of models was carried out, in which every reasonable theoretical and/or

empirical model was tested, as well as a one-factor model as the baseline model.

Once the factor structure was clear, the internal consistency of the INPIAS

factors or subscales was tested using Cronbach’s Alpha indices, and test-retest

reliability was examined with Pearson’s correlations between the two times of their

completion (one to two week interval). Convergent and divergent validity analyses were

conducted by computing Pearson’s correlations. The differences between high and low

dietary restraint (subclinical ED participants) were analyzed using Chi2 tests and t tests

in all the variables under study: demographic and questionnaire data, frequency of

EDITs, appraisals, emotional consequences, interference and control strategies. Finally,

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in order to control the load of depression, anxiety, worry, obsessionality, age, and BMI

scores on the INPIAS scores, ANCOVAs were also computed.

RESULTS

Confirmatory Factor Analyses of INPIAS

Six models of INPIAS-Part 1 were compared for their adequacy fit. Model 1 was a

single-factor model and included all the INPIAS-part 1 items. This model was used as a

baseline against which to test alternative factorial structures. Model 2 was a two-factor

model: Normative discontent and disordered eating. Model 3 was a three-factor model,

and the items were clustered on the basis of the way the intrusion can be experienced: as

a thought, as an image, or as an impulse. Model 4 was also a three-factor model, and the

items were clustered taking into account three different contents: Physical appearance

and dieting, exercising, and disordered eating. Model 5 was a three-factor model, and

the items were grouped on the basis of the specific setting in which each intrusion

occurs: Eating (before, during, or after eating), social context, and de-contextualized

intrusions. For Model 6, four factors were constructed: Physical appearance and dieting,

exercising, eating related intrusions, and disordered eating. Models 2, 4 and 6 come

from the exploratory factor analysis in a former study with the INPIAS (Perpiñá et al.,

2008). Models 3 and 5 were proposed on a rational basis.

Following the recommendation of Nasser Takahashi, and Benson (1997), the 50

items from INPIAS-Part 1 were grouped in 25 pairs according to their similar content.

Pearson’s correlations were calculated in order to test the statistical associations

between them (see Table 1). Indices for the six models tested are shown in Table 2. The

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best indices were obtained with Model 6, composed of four factors. A detailed analysis

of Model 6 showed that the overlap between factors 1 and 3 was very high (r = .908), so

they were grouped in one single factor, forming a new model (Model 7) consisting of

three factors with good standardized loadings (see Table 1). Table 2 shows that all the

fit indices for Model 7 were better than those for Model 6. The first factor in Model 7

was composed of items such as “I look horrible”, and “I shouldn’t eat any of this”, so it

was called Appearance and dieting. The second factor was called Exercising because it

grouped together all the items about this topic. And finally, factor 3 consisted of items

such as “I am going to vomit”, “Starting to eat without stopping”, and, therefore, was

called Purging and disordered eating.

For the INPIAS-Part 2-A, four models were tested. Model 1 was a single-factor

model: 16 items grouped into one factor. Model 2 had two factors derived from the

Perpiñá et al. (2008) previous study: Emotional consequences and appraisals; Thought-

Action Fusion and Overestimation of threat. Model 3 included three factors: Emotional

consequences, appraisals, and interference. Model 4 had two factors: Emotional

consequences and appraisals; thought-action fusion and overestimation of threat. The

difference between this model and Model 2 was that one item about “unacceptability of

the intrusion” was included here in the emotional consequences and appraisals factor.

Models 3 and 4 were proposed on a rational basis. Four CFA were computed to obtain

fit indices for the four models. The same criteria were used as in INPIAS-Part 1 (CFI,

GFI and AGFI > .90, SRMR and RMSEA < .08), but the procedure followed was item

by item (rather than item parceling). The best solution was obtained with Model 4 (see

Table 2). The standardized factor loadings for Model 4 are presented in Table 3. The

loading of item 7 is negative (higher score, more control of intrusive thoughts). Factor 1

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in this model was labelled Emotional consequences and personal meaning because it

clustered items about unpleasantness, insecurity, and doubts about the self when having

the EDIT. The second factor included 3 items about the belief that merely having the

thought causes catastrophic events or increases the likelihood of such events occurring,

and it was called Thought-Action Fusion (TAF) and responsibility.

Finally, four models were tested for the control and/or neutralizing strategies

associated with the most upsetting thought: Model 1 was a single factor model that

included the 22 items. The next model was based on previous exploratory analysis

(Perpiñá et al., 2008) and included 4 factors, one of them with two indicators (#4e: “I do

what the unwanted thought tells me”, and #10: “I don’t do anything to get rid of the

thought; I just let it be”). A sufficient condition for the identification of this model is to

have at least two indicators per factor, provided that all factors are empirically related.

However, as the data did not fit this condition, the model was not empirically identified

(Bollen, 1989) and, therefore, not testable. As a result, this model was substituted by the

next one. Model 2: four factor model: based on the above-mentioned model. Items #4e

and #10 were placed in factor 2, and two items about cognitive and behavioral

distraction were placed in a single factor. In Model 3, we tested the previously obtained

model (Perpiñá et al., 2008) without items #4e and #10. Model 4 was based on a

rational clustering of items in four factors: Anxiety control strategies, Thought-

suppression strategies, Obsessive-Compulsive (OC)-rituals, and Distraction. Table 2

shows the fit indices obtained using the item by item procedure for this part of the

questionnaire.

The best results were for Model 4, which included the four factors mentioned

above. The standardized loadings are shown in Table 3. Factor 1 grouped 5 items (e.g.,

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“reasoning with myself”, “trying to calm myself down”), and was labeled Anxiety

control strategies. The second factor, Thought-Suppression strategies, included 9 items

(e.g., “telling myself to stop”, “trying not to think anymore”). Factor 3, Obsessive-

Compulsive rituals, was composed of 4 items: “washing”, “checking”, “repeating” and

“ordering”. Finally, the Distraction factor included two items: “I distract myself by

thinking about something else” and “doing something”. Items 4 and 10 were excluded

from the CFAs.

Reliability of the INPIAS factors.

The internal consistency for every factor of INPIAS was calculated. The

Cronbach’s Alpha values for the three Part 1 factors were excellent: Appearance and

dieting: α=.97; Exercising: α=.92; Purging and Disordered Eating: α=.85. Regarding

INPIAS-Part 2-A, the alpha value was excellent for Emotional consequences and

personal meaning (α=.92), whereas it was only moderate for the TAF factor (α=.67).

The INPIAS-part 2-B internal consistency was excellent: Anxiety control strategies:

α=.79; Thought Suppression: α=.86; OCD-rituals: α= .80; Distraction: α= .80.

The temporal stability of INPIAS was satisfactory, as all the correlation

coefficients were p≤ 0.01, ranging from r=.92 to r= .83 (INPIAS Part 1), from r=.88 to

r=.80 (INPIAS Part 2-A), and from r=.82 to r=.59 (INPIAS Part-2B).

Convergent and Divergent Validity of the INPIAS

The size of the correlation coefficients between INPIAS Part-1 and depression,

anxiety and worry proneness ranged from low (.13) to moderate (.42), although all of

them were statistically significant (p<0.001). INPIAS’ convergent validity was

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calculated by correlating the eating and obsessive psychopathology scales (MBSRQ, RS

and C-BOCI) with INPIAS. Results show moderate to high significant correlations

between eating psychopathology measures and the INPIAs-Part 1 scales, with notably

high correlations with Overweight preoccupation (MBSRQ) and Concern about Dieting

(RS). Moreover, EDITs showed moderate correlations, with obsessive-compulsive

symptoms being higher with INPIAS-Part 2-A (Emotional consequences and personal

meaning, and TAF and responsibility) and with Thought-Suppression strategies

(INPIAs-Part 2-B). The relationships of the Body area satisfaction and Appearance

evaluation scales (MBSRQ) with INPIAS’ scales were reversed. These results appear in

Table 4.

Differences among low- and high- Dietary Restraint

For the second objective of the present study, the subjects were divided into two

sub-groups according to their restrained eating. A cut-off point of 16 on the Restraint

Scale was applied. There were 491 subjects in the Low Dietary Restraint group (LDR).

Of them, 337 were women (71.24%). The mean age of this group was 25.04 (SD= 6.24)

years (range: 14 to 46 years), and their mean BMI was 22.14 (SD= 3.10; range: 17.02-

30.16). The majority were single (81.9%), with a medium socio-economic level

(67.8%), and 63.1% had university studies. The High Dietary Restraint group (HDR)

included 83 subjects (71 women). The mean BMI of the group was 23.58 (SD= 3.28;

range: 17.58 - 32.42). Their mean age was 24.07 (SD= 5.21, range: 15-45) years; 81.9%

of them were single, 74.7% had a medium socio-economic level, and 56.6% had

university studies.

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Differences in socio-demographic variables between the LDR and HDR groups

were explored, and no differences were found in age, socio-economic level, marital

status), or level of studies. However they were not equally distributed by gender (χ2:

9.87, p<.05), as there were more women in the HDR group. All the t- tests performed to

examine between-groups differences in BMI (t(568): 3.72, p<.001), depression (t(29.60):

2.97, p<.01), worry (t(572): 5.14, p<.001), and obsessionality (t(103.15): 5.33, p<.001) were

significant, except for anxiety (BAI t(217): 1.04, p=.30). On all these variables, the HDR

subjects scored higher than the LDR subjects.

The t tests performed on the INPIAS-Part 1 were significant for the three factors

(see Table 5), with the HDR group having a greater frequency of EDITs about

Appearance and dieting (first factor), Exercising (second factor) and Purging and

Disordered Eating (third factor). Taking into account the mean values, the LDR group

was shown to have these modalities of EDITs from “never” to “rarely”, whereas the

HDR group reported having them “occasionally, a few times throughout the year.

As in the previous analyses between-groups differences were observed on age

and BMI, as well as on depression, worry, and obsessionality, we explored the

possibility that the between-groups results obtained in the INPIAS-first part factors

could be due to the above-mentioned differences. To this end, several ANCOVAs were

computed for each factor from INPIAS-Part 1. Results showed that the same significant

between-groups differences were found, even after controlling for the above-mentioned

variables.

The groups obtained statistically significant different scores on the two factors of

the INPIAS-Part 2-A (Emotional consequences and personal meaning, and TAF and

responsibility). In both factors, a difference of intensity was observed, as the HDR

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group obtained higher scores than the LDR group. Differences were maintained, after

controlling for age, BMI, BDI, PSWQ, and C-BOCI, only for the Emotional

consequences and personal meaning factor. These results indicate that, whereas for the

LDR group the most upsetting intrusion has slight emotional impact, in the HDR

individuals the emotional consequences are comparatively higher. However, the

differences between groups in the TAF and responsibility factor disappeared after

controlling for depression (F(1,199): 0.39, p= .53).

Finally, the analyses computed to compare the groups on the control strategies

individuals activate after having an upsetting EDIT (INPIAS-Part 2-B) showed

differences between the two groups on every factor. The ANCOVAs showed that,

regarding Anxiety strategies, the differences disappeared after controlling for BDI

(F(1,199): 0.04; p= .83), PSWQ (F(1,553): 2.13; p= .14) and C-BOCI (F(1,553): 0.57; p= .44).

On the Suppression, OC-rituals and Distraction strategy, the differences between

groups disappeared after controlling for BDI (F(1,198): 2.54, p= .11; F(1,199): 0.75, p= .38;

F(1,199): 0.12, p= .72, respectively).

DISCUSSION

Our first objective was to examine, in a large non-clinical community sample,

the factorial structure, reliability, and validity of the INPIAS, a new instrument

specifically designed to assess EDITs. The CFA revealed that the EDITs may be

reliably clustered into three different sets: about physical appearance and dieting, about

the need to do exercise, and related to purging and disordered eating. It is interesting to

note that the item contents in the first factor reveal the close relationship between the

over-valuation of the body and the need to diet, which has been indicated by several

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authors (Cooper & Shafran, 2008; van Strien, Herman, Engels, Larsen, & van Leeuwe,

2007). The third factor contents seem to be related to a pattern of disordered eating

(Tanofsky-Kraff & Yanovski, 2004), since they include EDITs which are nearer to

eating disorder psychopathology than those included in the other two factors. INPIAS-

Part 2-A, which focused on the emotional consequences, appraisals and interference

produced by the most upsetting EDIT, showed a two-factor structure: Emotional

consequences and personal meaning, and TAF and responsibility. And INPIAS-Part 2-

B was grouped in four factors about the control and/or neutralizing strategies associated

with the most upsetting EDIT: Anxiety control strategies, Thought-Suppression

strategies, OC-rituals, and Distraction. The internal consistency of the factors was

excellent, with the only exception of the TAF and responsibility factor. The temporal

stability of the instrument was satisfactory.

In sum, our first hypothesis was partially confirmed: the INPIAS factorial

structure obtained in the Perpiñá et al. study (2008) was replicated only for the second

section of the INPIAS. However, the structure of the first part was slightly different. In

our opinion, the current 3-factor structure more accurately identifies how the EDITs are

grouped on the basis of their contents. In fact, whereas the first two factors include

items that are probably very common in the non-clinical population, the items in the

third factor are nearer to eating psychopathology. Nevertheless, it is important to note

that the subjects experienced all the EDITs, which indicates that this modality of

cognitive intrusions is not, by itself, psychopathological. Finally, the divergence

between our data and those previously reported by Perpiñá et al. (2008), could be due to

the different statistical methodology used, as well as the higher number of participants

and their origin in the current study -community individuals.

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Regarding the second hypothesis, the results support the idea that the EDITs’

frequency (INPIAS-Part 1) is more associated with measures of ED than with other

symptoms (depression, anxiety, and worry tendencies), which supports the convergent

and divergent validity of the first section. The higher associations found with

Overweight preoccupation (MBSRQ) and Concern about dieting (RS), suggest that the

frequency with which people experience EDITs is associated with worries about

overweight and the need to diet. Moreover, the positive aspects of body image, such as

Body satisfaction and Appearance evaluation scales (MBSRQ), which were inversely

related to the frequency of EDITs, reveal that the higher the body esteem, the lower the

occurrence of EDITs. This result supports the notion that increased self-esteem and a

positive body image are protective factors against ED (Neumark-Sztainer, 2009).

However, the pattern of associations found in the second part of the INPIAS

showed that the emotional and behavioral consequences of experiencing an upsetting

EDIT is not mainly related to ED measures, but also to other general psychological

distress. A special comment should be made regarding the Thought-Action Fusion and

Responsibility factor, which was more associated with OCD symptoms than with the

other symptom measures. The TAF concept, which was formulated in the context of

OCD cognitive models (Rachman & Shafran, 1999) is analogous to the Thought-Shape

Fusion postulated by Shafran, Teachman, Kerry, and Rachman (1999), which has been

associated with ED. From this latter perspective, a greater association of the INPIAS-

TAF factor with ED than with OC-measures would be expected in our study, but this

was not the case, possibly due to the fact that the items on the INPIAS evaluate thought-

action fusion, but not specifically thought-shape fusion.

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The second objective was to explore the evidence about the continuity from

normality to abnormality of the EDITs’ frequency and consequences. To this end,

differences between Low and High restraint participants were examined. The results

showed that the LDR group obtained lower scores than the HDR on the INPIAS. The

LDR individuals experienced EDITs with a very low frequency. Especially low was the

frequency of EDITs about purging and disordered eating. Consequently, the emotional

impact and the use of maladaptive thought control strategies were also low. In contrast,

the individuals in the HDR group exhibited a more intense emotional reaction and

scored higher on the dysfunctional appraisals and personal meaning factor when

experiencing an upsetting EDIT.

However, the differences between groups found in TAF and responsibility

appraisals disappeared after controlling for depression, which suggests a significant

mediator role of dysphoric mood between these evaluative appraisals and the experience

of EDITs. With regard to control strategies, the differences between groups also

disappeared after controlling for depression, worry and obssesionality.

Taken together, all of the above-mentioned results indicate that the INPIAS is a

reliable and valid instrument to evaluate the content and frequency of EDITs in non-

clinical samples, since it is more associated with ED measures than with anxiety or

depression. Moreover, our results also showed that, in normal community people, an

upsetting EDIT has negative emotional consequences, interferes with ongoing activity,

activates dysfunctional appraisals, and promotes a set of strategies in order to keep the

flow of thoughts under control. This pattern of consequences is similar to the one

observed with unwanted intrusions analogous to obsessions (Belloch, Morillo, Lucero,

Cabedo, & Carrió, 2004; Purdon & Clark, 1993; 1994).

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The results support the idea of continuity from normal to abnormal unwanted

intrusive cognitions related to ED contents. The data also suggest the notion that the

escalation from a normal EDIT to a pathological one does not rely on its mere presence,

but rather on its emotional impact, the dysfunctional appraisals and personal meaning it

produces, and the control strategies that are activated. This sequence is analogous to the

one postulated by the cognitive models on OCD, and opens up an interesting way to

understand the similarities between ED and OCD (Jones, Harris, & Leung, 2005;

Speranza et al., 2001).

There are limitations in the current study. The INPIAS, a self-report, is limited

in that it can only analyze the cognitive event as a final product. Another limitation is

the way the participants were screened for psychological disorders, since the evaluator

obtained this information by relying exclusively on the verbal information provided by

the individual, although the scores on the BDI, BAI, and CBOCI were also examined.

In order to conduct a more accurate analysis of EDITs’ dimensionality, ED

patients must be included in future studies. These studies would ideally include all ED

subtypes. In addition, it would be interesting to study EDITs through the illness process

and investigate whether there are changes in the experience of the EDITs after recovery.

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ACKNOWLEDGEMENTS

This study was supported in part by the Spanish Ministerio de Ciencia e Innovación

(Grant no. PSI2009-10957), the Conselleria de Empresa, Universidad y Ciencia.

Dirección general de Investigación y Transferencia Tecnológica. Generalitat

Valenciana (Grant no. AE/07/022), the Spanish Ministerio de Ciencia y Tecnología

and EC Feder funds (Grant no. SEJ2006-03893/PSIC).

CIBER Fisiopatología de la Obesidad and Nutrición (CIBEROBN) is an initiative of

ISCIII.

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Table 1. Item parcel correlations and standardized loadings of Model 7 for INPIAS-Part 1.

Pair Items rxy Factor λ Pair Items rxy Factor λ

1 1-2 .738 1 .722 14 36-20 .830 3 .860

2 6-17 .714 3 .655 15 34-42 .783 1 .751

3 8-15 .925 1 .842 16 43-48 .802 1 .708

4 9-16 .694 2 .894 17 47-49 .597 1 .869

5 21-50 .765 2 .910 18 22-23 .395 3 .677

6 30-37 .751 2 .836 19 7-13 .694 1 .867

7 19-29 .874 1 .860 20 10-14 .752 1 .689

8 24-35 .591 1 .736 21 3-4 .572 1 .449

9 28-44 .851 1 .910 22 25-33 .619 1 .888

10 45-46 .739 1 .881 23 39-41 .791 1 .863

11 31-32 .887 1 .845 24 11-12 .524 3 .494

12 27-40 .756 1 .845 25 5-18 .485 1 .798

13 26-38 .450 1 .808

rxy: Pearson correlation, p<0.005

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Table 2. Fit indices for the INPIAS.

Models CFI GFI AGFI SRMR RMSEA χ2 df p<

INPIAS-Part 1: Eating-related intrusive cognitions

Model 1 0.742 0.68 0.622 0.061 0.094 1705.7042 275 .001

Model 2 0.786 0.719 0.662 0.075 0.087 1461.0971 270 .001

Model 3 0.754 0.694 0.630 0.061 0.093 1635.7152 269 .001

Model 4 0.828 0.773 0.726 0.059 0.078 1225.0984 269 .001

Model 5 0.787 0.726 0.668 0.057 0.087 1452.1944 268 .001

Model 6 0.899 0.799 0.758 0.073 0.070 1031.5849 269 .001

Model 7 0.917 0.784 0.738 0.043 0.054 728.7640 268 .001

INPIAS-Part 2-A: Emotional consequences, appraisals and interference

Model 1 0.829 0.841 0.792 0.069 0.089 570.75333 104 .001

Model 2 0.884 0.888 0.852 0.078 0.074 418.5791 103 .001

Model 3 0.854 0.865 0.819 0.064 0.084 503.3471 101 .001

Model 4 0.912 0.904 0.872 0.048 0.065 342.3481 102 .001

INPIAS-Part 2-B: Thought Control Strategies

Model 1 0.771 0.790 0.746 0.079 0.089 1145.1416 209 .001

Model 2 0.898 0.882 0.853 0.060 0.060 619.1832 203 .001

Model 3 0.981 0.895 0.865 0.054 0.059 483.4485 164 .001

Model 4 0.933 0.912 0.887 0.053 0.053 423.4538 164 .001

CFI: Comparative Fit Index; GFI: Goodness of Fit Index; AGFI: Adjusted Goodness of

Fit Index; SRMR: Standardized RMR; RMSEA: Root Mean-Square Error of

Approximation.

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Table 3. INPIAS-Part 2: Standardized loadings

INPIAS-Part 2-A: Model 4 INPIAS-Part 2-B: Model 4

Item λ Item λ

Factor 1 1 0.818 Factor 1 5 0.663

2 0.834 6 0.598

3 0.782 7 0.692

0.713 8 0.732

11 0.656

4

5

6

0.710

0.766 Factor 2 3 0.584

7 -0.536 4f 0.501

8 0.719 9 0.782

9 0.772 12 0.607

10 0.471 13 0.697

11 0.629 14 0.828

14 0.675 15 0.649

16 0.807 16 0.804

Factor 2 12 0.530 17 0.358

13 0.691 Factor 3 4a 0.779

15 0.531

4b

4c

0.660

0.618

4d 0.780

Factor 4 1 0.810

2 0.834

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Table 4. Correlations between INPIAS and questionnaire measures (N=574)

INPIAS-

Part 1

INPIAS-

Part 2-A

INPIAS

Part 2-B

Questionnaire Measures

AD E PDE EPM TAF AS S OC D

Beck Depression Inventory .42* .29* .35* .42* .21* .27* .36* .17* .21*

Beck Anxiety Inventory .23* .13* .23* .26* .18* .21* .23* .16* .05

Penn-State Worry Quest. .36* .29* .21* .38* .27* .27* .35* .21* .21*

Clark-Beck Obsessive Compulsive Inventory

Obsessions .44* .37* .35* .50* .50* .36* .47* .31* .22*

Compulsions .35* .29* .27* .36* .40* .29* .36* .33* .11*

Total score .43* .36* .33* .48* .49* .36* .46* .35* .18*

Multidimensional Body-Self Relations Questionnaire

Appearance evaluation -.49* -.36* -.32* -.42* -.23* -.03 -.21* -.12* -.10*

Appearance orientation .37* .31* .23* .33* .20* .16* .21* .19* .18*

Body-Weight satisfaction -.51* -.34* -.32* -.43* -.25* -.07 -.24* -.16* -.13*

Over-weight preoccupation. .75* .60* .52* .55* .30* . 16* .22* .22* .16*

Self-classified weight .44* .33* .21* .32* .08 .07 .17* .13* .13*

Restraint Scale

Concern for Dieting .76* .63* .54* .61* .33* .19* .35* .30* .21*

Weight fluctuation .51* .41* .38* .41* .22* .12* .20* .19* .11*

AD: Appearance and Dieting; E: Exercising; PDE: Purguing and Disordered Eating;

EPM: Emotional consequences and personal meaning; TAF: Thought-Action Fusion

and responsibility; AS: Anxiety strategies; S: Though-Suppression strategies; OC:

Obsessive-Compulsive rituals; D: Distraction. *p≤0.05.

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Table 5. Between-groups differences in the INPIAS subscales

INPIAS subscales LDR

(N=491)

HDR

(N=83)

t(df)

Appearance & Dieting 0.94

(0.83)

2.85

(1.06)

t(99,89)

15.56**

Exercising 1.66

(1.22)

3.57

(1.27)

t(568)

13.00**

Part1

Purguing & Disordered

Eating

0.27

(0.40)

1.16

(1.08)

t(85.96)

7.32**

Emotions & Meaning 0.81

(0.61)

1.86

(0.70)

t(554)

13.92**

Part

2-A

TAF & Responsibility 0.29

(0.44)

0.72

(0.82)

t(90.46)

4.65**

Anxiety strategies

1.27

(0.89)

1.56

(0.77)

t(124.32)

3.05*

Suppression

0.92

(0.75)

1.52

(0.76)

t(553)

6.66**

OC- rituals

0.37

(0.60)

0.74

(0.78)

t(99.83)

4.07**

Part

2-B

Distraction

1.54

(1.14)

2.02

(0.93)

t(129.14)

4.12**

In the two first columns, data are expressed as M (SD); **p<0.001. *p<0.005; TAF: Thought-

Action Fusion; OC: Obsessive-Compulsive

LRD: Low Dietary Restraint; HRD: High Dietary Restraint.

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