Eating Disorder Belief Questionnaire

Description
The Eating Disorder Belief Questionnaire (EDBQ: Cooper, Cohen-Tovee, Todd,

Wells, & Tovee, 1997) assesses the core beliefs and underlying assumptions

associated with eating disorders. It is a self-report questionnaire with a total of

32 individual items. It breaks down into four subscales. These are: negative self-

beliefs (10 items), weight and shape as a means to acceptance by others (10

items), weight and shape as a means to self-acceptance (6 items), and control

over eating (6 items). The first subscale represents negative self or core beliefs

while the remaining three represent underlying assumptions. The constructs are

defined in ways consistent with those employed in Beckian cognitive theory and

therapy (e.g. Beck, Freeman, & Associates, 1990). In keeping with the authors’

clinical and research experience that the emotional, ‘felt sense’ of beliefs rather

than only their rational belief, is important in eating disorders respondents are

asked to complete the measure ‘based on what you emotionally believe or feel,

not on what you rationally believe to be true’. In addition, and also consistent

with the notion in Beckian literature, that beliefs and assumptions are relatively

stable, respondents are asked to ‘choose the rating that best describes what you

usually believe, or what you usually believe most of the time’. Each item is rated

on a visual analogue scale (scores ranging from 0-100). The end points are

anchored at ‘I do not usually believe this at all’ and ‘I am usually completely

convinced that this is true’. A score is obtained for each subscale by adding up

the total for the subscale and dividing by the number of items contributing to the

subscale. Four scores, one for each subscale, between 0 and 100 are thus

obtained. The measure has been validated as a measure of four subscales, not for

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use when a single score encompassing all items is computed. The items can be

seen in Table 1. Table 2 indicates which items contribute to each subscale. The

questionnaire is free to use. The Eating Disorder Belief Questionnaire requires

only basic knowledge about the administration of psychological questionnaires

to use. It has been successfully administered in a number of ways, via post, in

groups in classroom settings, and using internet survey software. Time to

complete it will depend on whether patient samples are used or not, with

patients typically taking longer than non-patients. On average it can be

completed in about 5 minutes. The Eating Disorder Belief Questionnaire is not a

diagnostic measure, and has no diagnostic cut off scores.

Historical Background

The Eating Disorder Belief Questionnaire was the first measure to assess both

the beliefs and the assumptions thought to be relevant specifically to eating

disorders. It was developed by surveying existing measures in the field and by

drawing on the authors’ clinical experience of conducting therapy, particularly

cognitive therapy, with people with eating disorders, and their previous research

experience. It differs from many related and commonly used measures of these

types of cognition in the eating disorder field in that it was designed specifically

with eating disorders in mind. It has strong links to cognitive theories of eating

disorders that highlight core beliefs and underlying assumptions as part of the

core features of eating disorders (see Cooper, 2005). It has played an influential

and pioneering role in increasing interest in core beliefs that do not reflect

eating, weight and shape related content in those with eating disorders. This (the

negative self-belief) subscale of the measure has recently been developed into a

promising multidimensional core belief measure relevant to people with eating

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disorders (Fairchild & Cooper, 2010). The Eating Disorder Belief Questionnaire

has always been free to use, consistent with the authors’ philosophy that

research into eating disorders should be made easy to conduct, especially for

junior researchers and students. The questionnaire has been translated into

several languages other than English. Its development is notable in that a large

number of items were generated for possible inclusion in the final measure by

four highly experienced cognitive therapists with considerable experience of

clinical and research work with people with eating disorders. In line with best

practice for questionnaire development the measure was then factor analysed,

with the revised measure being factor analysed once more on a completely new

sample in order to maximise validity.

Current Knowledge

Psychometric properties

A number of studies designed to investigate the psychometric properties of the

Eating Disorder Belief Questionnaire were reported in the original paper

(Cooper et al., 1997). Unlike many measures in the field it has strong

psychometric properties. Subsequent studies also contain data relevant to its

psychometric properties, although some of this data was collected to test

hypotheses.

In originally developing the measure factor analysis was completed on a large

sample of young women (N=249). Four factors were retained and retained items

were factor analysed on a new sample of young women (N=254). Identical

factors were identified, with only one item being dropped from the new scale

due to cross loading.

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Alpha reliabilities (internal consistency) for these subscales ranged from .86 to .

94. Item total correlations ranged from .82 to .94.

Construct validity. Convergent and discriminant validity were both investigated.

As expected the Eating Disorder Belief Questionnaire subscales were all

moderately correlated with measures of eating disorder related symptoms but

not with body mass index. Scores on all four subscales also discriminated

successfully between healthy volunteers and two patient groups, one with a

diagnosis of anorexia nervosa and one with a diagnosis of bulimia nervosa. As

expected the two patient groups had significantly higher scores than the healthy

volunteer group on all four subscales.

Criterion related validity. Regression analyses indicated that depression was best

predicted by the negative self-beliefs subscale, while eating disorder symptoms

were best predicted by the control over eating subscale (and negatively by the

negative self-beliefs subscale).

The Eating Disorder Belief Questionnaire in different groups

As is typical of many self-report questionnaire measures where large sample

sizes are required for factor analysis the Eating Disorder Belief Questionnaire

was developed in a community sample, and no screening for eating disorders

occurred. However, as noted above, part of its validation did include

administration to two groups of patients with an eating disorder, one with

anorexia nervosa and one with bulimia nervosa, with all groups scoring as

predicted.

Since its development the Eating Disorder Belief Questionnaire has been used to

explore the existence of core beliefs and assumptions in other groups with eating

disorders, including adolescents with a diagnosis of anorexia nervosa, and in

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groups considered of relevance to eating disorders, for example, dieters and

mothers of overweight girls. With control groups of healthy volunteers, such

studies provide further evidence for its convergent validity in a range of groups

with eating disorders, and for its discriminant validity, i.e. in not being relevant

to those without an eating disorder or related symptoms.

Current Issues

Theory building

One important current issue is where and how core beliefs and assumptions fit

into any new theoretical understanding of eating disorders. Treatment outcome

for most eating disorders is less than ideal, and it is widely agreed that more

effort needs to be put into developing better explanatory models. The Eating

Disorder Belief Questionnaire, by providing a psychometrically sound measure

of relatively novel constructs in this area, can potentially make a significant

contribution to theory development.

Treatment evaluation

Anecdotally, clinicians are increasingly using the constructs of negative self-

beliefs and assumptions of the type assessed in the Eating Disorder Belief

Questionnaire, although they may be given rather different names. For example,

negative self-beliefs are also commonly referred to as core beliefs or schema.

Two treatment manuals both place significant emphasis on beliefs and

assumptions (Cooper, Todd, & Wells, 2009; Waller, Cordery, Corstorphine,

Hinrichsen, Lawson, Mountford, V, & Russell (2007), particularly in the context

of cognitive therapy of eating disorders. However, few clinicians routinely take

reliable or valid measures of these constructs during therapy, either as part of

outcome or process assessment. This makes it difficult to evaluate the

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effectiveness of the treatment but also to tell why it may have worked, if it has, or

conversely why it has not worked. Using the Eating Disorder Belief

Questionnaire would go some way towards addressing these issues, and help

provide a much needed evidence base for therapy in eating disorders,

particularly more recent adaptations or versions that have not been adequately

tested in randomised control trials.

Adolescents

There has been particular concern recently about the high rate of eating

disorders and lack of adequate treatment for adolescents with eating disorders.

The Eating Disorder Belief Questionnaire has been administered to a large group

of adolescents (N=367) and factor analysed to see if the structure can be

replicated in this group. This is important because many eating disorders begin

in, or are characteristic of, adolescents and young people. Overall, the factor

structure was almost identical but with some suggestion, perhaps a

developmental feature, that factors were less separate from each other. Overall

the results of this study, and the psychometric analyses accompanying it (Rose,

Cooper, & Turner, 2006), suggest that the measure is also useful in young people.

Men

The questionnaire has not been factor analysed in men, nor have its

psychometric properties been analysed in detail in this group. It has been

administered to test hypotheses and generated useful findings in at least two

studies of men drawn from nonclinical community samples.

Mediation – a causal role for beliefs and assumptions

One study has been conducted to test the potential role of Eating Disorder Belief

Questionnaire beliefs and assumptions in model building in eating disorders,

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investigating links between early experience and eating disorder symptoms. It

has been strongly argued that models in eating disorders need to include core

beliefs and assumptions (e.g. Cooper, Todd & Wells, 2009). Moreover, it has been

suggested that it would be useful in theory development to understand how they

might be related to early experiences. One study, using a community sample,

which set out to investigate this, found that core beliefs mediated, i.e. had a

potentially causal role, in the relationship between parental bonding and eating

disorder symptoms.

Eating Disorder Belief Questionnaire and mood

The Eating Disorder Belief Questionnaire development study found that the

negative self-beliefs subscale scores were related to mood, more so than to

eating disorder symptoms. A study was subsequently conducted to disambiguate

this potentially complex relationship. It found a cluster of beliefs that appeared

to be specifically related to high levels of eating disorder symptoms and not also

to depressed mood. This is helpful because it suggests that the beliefs currently

part of the negative self-beliefs subscale may include some that are unique to

eating disorder symptoms and not also typical of depression. This study in

particular provided impetus for the development of a multi-dimensional core

belief measure relevant to eating disorders where it might be possible to identify

specific subscales uniquely characteristic of eating disorders and their symptoms

(Fairchild & Cooper, 2010).

Criticisms

Most studies using the Eating Disorder Belief Questionnaire have been

conducted in the UK so it is not clear if the measure translates easily to other

countries and cultures. Some cross-cultural work would be useful.

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All studies have been done by, or with, the collaboration of the senior author, so

some independent studies by other investigators are really needed in order to

see if the psychometric properties and results found to date can be replicated.

Mood is an important variable to assess at the same time as the items on the

Eating Disorder Belief Questionnaire. While depression has been measured

routinely, and some work has tried to disambiguate its relationship to eating

disorder symptoms, it has become clear more recently that anxiety will be

important to investigate in a similar way in the future.

Future Directions

The negative self-belief subscale scale is relatively brief given the wide number

of different core beliefs encountered clinically. In order to address this a multi-

dimensional core belief measure relevant to eating disorders has now been

developed (Fairchild & Cooper, 2010). Further work using this, as well as the

negative self-beliefs subscale of the Eating Disorder Belief Questionnaire, to

investigate negative self-beliefs is needed. It will be important to evaluate the

relative merits of the negative self-beliefs subscale and the new measure.

The Eating Disorder Belief Questionnaire could usefully be factor analysed in a

clinical group, in young men, and in non-traditional eating disorders, including

some of those now identified in the Diagnostic and Statistical Manual, Version V

(American Psychiatric Association, 2013). This would establish whether the

factor structure holds in a range of eating disorders and in other relevant groups.

It may also have relevance to obesity and binge eating disorder.

The Eating Disorder Belief Questionnaire could have a role in treatment

evaluation, investigating whether beliefs and assumptions change with different

types of therapy. This could contribute to our understanding of how different

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treatments may work. The measure could also be used during therapy as a

process measure. For example, it could help therapists identify where to focus

their therapeutic endeavours. There are now suggestions for suitable therapeutic

strategies adapted for eating disorders for both constructs (Cooper et al., 2000;

Cooper et al., 2009; Waller et al., 2007).

It will be important to investigate how the negative self-beliefs subscale relates

to the Young Schema Questionnaire (www.schematherapy.com), and to see

whether a relatively brief measure of these beliefs has any significant scientific

merit over and above that of the Young Schema Questionnaire. It has definite

practical advantages in being significantly shorter and thus much less time

consuming to complete, but it is not clear if it has theoretical or empirical

advantages too.

Conclusion

Despite the development of a new, multidimensional core belief measure, the

Eating Disorder Belief Questionnaire remains valuable as the only measure of

underlying assumptions relevant to eating disorders, and because it provides a

quick, very brief and easy to use, measure of negative self-beliefs specifically for

those with eating disorders. It is applicable and potentially useful in a broad

range of clinical and research settings.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of

mental disorders, version 5. Washington, DC: American Psychiatric Association.

Beck, A.T., Freeman, A., & Associates. (1990). Cognitive therapy of personality

disorders. New York: Guilford Press.

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Cooper, M.J., Cohen-Tovee, E., Todd, G., Wells, A., & Tovee, M. (1997). The eating

disorder belief questionnaire: preliminary development. Behaviour Research

and Therapy, 35, 381-388.

Cooper, M.J., Todd, G., & Wells, A. (2009). Treating bulimia nervosa and binge

eating: An integrated metacognitive and cognitive therapy manual. London:

Taylor & Francis.

Cooper, M.J., Todd, G., & Wells, A. (2000). A self-help cognitive therapy

programme for bulimia nervosa. London: Jessica Kingsley.

Fairchild, H. & Cooper, M.J. (2010). A multidimensional measure of core beliefs

relevant to eating disorders: Preliminary development and validation. Eating

Behaviours, 11, 239-246.

Rose, K.S., Cooper, M.J., & Turner, H. (2006). The eating disorders belief

questionnaire: psychometric properties in an adolescent sample. Eating

Behaviours, 7, 410-418.

Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V.,

& Russell, K. (2007) Cognitive-behavioral therapy for the eating disorders: A

comprehensive treatment guide. Cambridge: Cambridge University Press.

Table 1: Eating Disorder Belief Questionnaire items

1. I’m unlovable
2. If my flesh is firm I’m more attractive
3. I’m ugly
4. I’m useless
5. I’m a failure
6. If I eat a forbidden food I won’t be able to stop
7. If my stomach is flat I’ll be more desirable
8. If I lose weight I’ll count more in the world
9. If I eat desserts or puddings I’ll get fat

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 10. If I stay hungry I can guard against losing control and getting fat
11. I’m all alone
12. If I eat bad foods such as fats, sweets, bread and cereals they will turn into

fat
13. I’m no good
14. If I eat normally I’ll gain weight
15. If I eat three meals a day like other people I’ll gain weight
16. If I’ve eaten something I have to get rid of it as soon as possible
17. I’m not a likeable person
18. If my hips are thin people will approve of me
19. If I lose weight people will be friendly and want to get to know me
20. If I gain weight it means I’m a bad person
21. If my thighs are firm it means I’m a better person
22. I don’t like myself very much
23. If I gain weight I’m nothing
24. If my hips are narrow it means I’m successful
25. If I lose weight people will care about me
26. If my body shape is in proportion people will love me
27. I’m dull
28. If I binge and vomit I can stay in control
29. I’m stupid
30. If my body is lean I can feel good about myself
31. If my bottom is small people will take me seriously
32. Body fat/flabbiness is disgusting

Table 2: Items on the Eating Disorder Belief Questionnaire contributing to each

subscale

Subscale 1: Negative self-beliefs 1, 3, 4, 5, 11, 13, 17, 22, 27, 29

Subscale 2: Weight and shape as a means to acceptance by others 8, 18, 19, 20,
21, 23, 24, 25, 26, 31

Subscale 3: Weight and shape as a means to self acceptance 2, 7, 9, 12, 30, 32

Subscale 4: Control over eating 6, 10, 14, 15, 16, 28

For: “Encyclopaedia of Feeding and Eating Disorders”

Edited by: Tracey Wade

Myra Cooper
University of Oxford

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5th August, 2016

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