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Systematic Review: Background: Ambivalence about change is a significant barrier in the treatment of anorexia nervosa (AN). Better understanding of the perceptions that patients hold about AN could help inform interventions to overcome these barriers. The Self-Regulation Model (SRM) of Illness may provide a method with which to better understand illness perceptions in AN, but its use in mental health has been questioned. Objectives: This systematic review summarises and synthesises the qualitative literature investigating the perceptions of AN held by people with the diagnosis and the extent to which these perceptions were explained by the SRM. Method: A search protocol based on PRISMA1 guidelines was developed prior to commencing the review. Four databases were searched (MEDLINE, PsycINFO, Embase, and CINAHL), alongside grey literature sources (Open Grey, UK Clinical Trials Gateway, Ethos, and Grey Literature Report) and forwards and backwards citation chasing. Screening was conducted by one reviewer using predetermined criteria; a sample was checked by a second reviewer. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) qualitative checklist, with a sample checked by a second reviewer. Framework synthesis was used to synthesise the data. Results: The search returned 817 results. 753 were excluded following title and abstract screening, and a further 46 were excluded after full-text screening. The final sample consisted of 18 journal articles and one unpublished Masters thesis. Five themes were identified from the framework synthesis. These were ‘Identity’, ‘Cause’, ‘Consequences’, ‘Timeline’, and ‘Efficacy’. Conclusions: Findings from this review suggest refinements to the SRM, which may improve its utility when working with people with AN. The findings of the review are limited by the under-representation of certain demographic groups, e.g., men. Exploration of the relationships between different aspects of IPs, stigma, clinical outcomes, and stages of change will be an important focus for future research. Empirical Paper: Objective: Compulsive exercise is associated with poor clinical outcomes in anorexia nervosa (AN). The mechanisms underlying this relationship are still not well understood, neither is the prospective longitudinal relationship between compulsive exercise and eating pathology through the course of treatment. This research therefore aimed to test the hypothesis that compulsive exercise at admission would predict eating pathology at discharge in an adolescent inpatient setting, controlling for baseline eating pathology and potential confounding factors. It also aimed to test the hypothesis that change in affect from admission to mid-way through treatment would mediate the relationship between compulsive exercise and residual eating pathology. Methods: Routine outcome measures (the Compulsive Exercise Test, the Eating Disorders Examination Questionnaire, the State Trait Anxiety Inventory, and the Children’s Depression Inventory) were obtained from adolescent inpatients with a diagnosis of anorexia nervosa (N = 50) at admission, 85% ideal body weight (IBW), and discharge. The data was analysed using hierarchical multiple regression. Results: Compulsive exercise at admission significantly predicted residual eating pathology at discharge after controlling for eating pathology at admission, age, and treatment duration. This effect was not mediated by change in affect, as compulsive exercise at admission did not significantly predict change in anxiety and depressive symptoms between admission and 85% IBW. Change in anxiety between admission and 85% IBW did significantly predict residual eating pathology independently of compulsive exercise. Conclusion: The unique predictive ability of the CET provides support for a separate theoretical model of compulsive exercise, as there appear to be factors specific to compulsive exercise that maintain eating pathology. The findings suggest that assessing compulsive exercise at the start of treatment may be helpful in identifying individuals at risk of residual symptoms of AN following treatment. This could offer services a different method of identifying at-risk individuals and tailoring interventions accordingly.

Background: The prevalence of eating and exercise psychopathology in athletes is higher when compared to the general population. A number of individual (e.g., psychological wellbeing, age, BMI, gender) and sport-specific (e.g., sport type) factors have been demonstrated to impact on athletes' risk of eating and exercise psychopathology. In particular, an athlete's teammates represent a unique source of social influence which requires investigation. Aim: The overarching aim of this thesis was to improve our understanding of the mechanisms through which teammates influence athletes' eating and exercise psychopathology, and the circumstances under which these influences are facilitated. Methods: A systematic review was first conducted to synthesise findings from existing studies and identify key literature gaps. Five empirical studies were then conducted, building on the limitations and gaps identified in the review. A triangulation of quantitative methodologies (i.e., cross-sectional, longitudinal, mediation, social network, experimental) was deemed appropriate to accurately determine the impact of teammates on athletes' eating and exercise psychopathology. Main Findings: Modelling of teammates' disordered weight control behaviours and perceiving a pressure from teammates to lose weight/change shape were identified as key cross-sectional and longitudinal predictors of athletes' increased symptoms of eating and exercise psychopathology. However, having supportive teammate friendships was identified as a key predictor of reduced eating psychopathology and increased engagement with healthy exercise behaviours (i.e., to improve mood). Although levels of eating and exercise psychopathology were generally found to remain stable over time, certain athletes appear to be at an increased risk and demonstrate more changeable behaviours. Sport related factors (e.g., sport type) were not found to have a consistent impact on eating and exercise psychopathology, however, gender differences were apparent. Female athletes perceived a greater level of teammate influence and a greater variance in their eating/exercise psychopathology was explained by both positive and negative teammate influences. Furthermore, indices of psychological wellbeing (i.e., self-esteem, anxiety and depression) were identified as significant mediators of relationships between teammate influences and eating/exercise psychopathology, and an athletes' positioning in their team social network (i.e., on the periphery of the team vs well connected to teammates) was found to impact on the severity of their eating/exercise psychopathology. Finally, a strong matching effect was identified whereby female athletes imitated each other's intake for unhealthy snack food. Implications: Taken together, the findings indicate that teammates can significantly influence athletes' eating and exercise psychopathology. There is need for coaches to be educated as to the negative and positive impact teammates can have, the factors that increase athletes' susceptibility to negative teammate influences, and the importance of striving for cohesive teams with supportive teammate friendships. Moreover, athletes need to be made aware that their teammates are likely to model their eating and exercise behaviours, and should therefore be encouraged to engage with healthy eating practices, taking steps to reduce pre-occupation with weight/shape.

Background: The incidence of eating psychopathology in athletes is considerably higher than in the general population. Facilitating the early identification and successful management of eating problems in this group is therefore essential. Objectives: The thesis aimed to improve our empirical understanding of the identification and management of eating problems in athletes. Three areas were investigated. First, a measure of compulsive exercise was evaluated as a method of identification of eating psychopathology in athletes. Second, the thesis explored coach methods of identification and management of eating problems among their athletes. Finally, athlete experiences of disclosing and seeking treatment for eating disorders were explored. Main findings: The Compulsive Exercise Test was found to be a useful measure in screening for eating psychopathology in athletes. Track and field coaches relied heavily on the physical symptoms of disordered eating when identifying potential eating problems in athletes. Coaches described difficulties in identifying eating psychopathology in athletes, and in signposting athletes to appropriate support. Individual differences in the perceived value of disclosing an eating disorder were discovered among athletes currently seeking treatment. Lastly, athletes described struggling to engage with their eating disorder treatment programme, particularly where exercise was restricted or reduced. Implications: The findings suggest a need for greater support, education and resources for coaches and sports professionals in identifying and facilitating treatment access among their athletes. The Compulsive Exercise Test may be one way to assist sports professionals in identifying athletes with elevated levels of eating psychopathology. Athletes may be more willing to engage with treatment programmes when they are closely involved in goal setting and their exercise and sporting commitments are incorporated where possible.

Background: The highly driven and often excessive exercise seen in eating disorder patients can be defined as a compulsive behaviour, and is often performed for weight control reasons, as well as for mood regulatory purposes. Compulsive exercisers often exercise in a rigid and rule-driven manner and predominantly report no enjoyment from the activity. Importantly, compulsive exercise has negative clinical implications, such as prolonging eating disorder treatment and representing a key factor in eating disorder relapse. However, despite these negative clinical implications and the large percentage of patients that may experience these harmful and detrimental behaviours, the body of literature examining the aetiology of compulsive exercise is relatively scarce and lacks a coherent theoretical underpinning. Objectives: This thesis aimed to provide the first known investigations into the possible correlates and risk factors for compulsive exercise in adolescent boys and girls. Main Findings: The key prospective predictors of compulsive exercise found in this thesis were self-perfectionism and obsessive-compulsiveness for boys. For girls, internal dysfunctional emotion regulation and a perceived media pressure to be thin were the key risk factors for compulsive exercise. Implications: The results from the thesis suggest that psychological factors are important in the development of compulsive exercise in boys, whereas in girls, a combination of dysfunctional emotion regulation and socio-cultural pressure to be thin could lead to the development of compulsive exercise cognitions and attitudes. Further research is needed to replicate and extend these results, although these thesis findings still provide useful empirical evidence to inform prevention and early intervention programmes for compulsive exercise in adolescents.

According to Brewer, Davis, Kalmbach, Kaptein, Katzman and Kirsch (1997), problematic exercise occurs in approximately 80% of anorexia nervosa patients and 55% of bulimia nervosa patients. Thus, a comprehensive understanding of unhealthy exercise is necessary for its assessment as well as eating disorder prevention and intervention. One term used to describe unhealthy exercise is compulsive exercise. Although compulsive exercise has been regarded as problematic in the development, treatment, and outcome of eating disorders, little research has investigated the risk factors for this behavior. Given the influence of body image disturbances on disordered eating and the relationship between compulsive exercise and disordered eating attitudes, this is extremely problematic. In the present study, it was hypothesized that the avoidance body self (feared for fat self) would be a stronger predictor of compulsive exercise behavior than approach body selves (hoped for thin self). Further, it was hypothesized that while these body image discrepancies would be significant predictors of compulsive behavior for both men and women, women would experience larger discrepancy scores than men. Overall, it was found that the ideal body self significantly predicted the avoidance and rule-driven behavior subscale as well as the exercise rigidity subscale. However, the ought and feared body selves did not significantly predict any of the compulsive exercise subscales. Further, it was found that women had larger ideal, ought and feared discrepancy scores than men.