A functional analysis of binge-eating

Do different psychopathological pathways into eating disorder necessitate different therapeutic goals and/or approaches?

This paper present a plea for a more flexible therapeutic approach which focuses not only on the underlying cognitions, behaviours and emotions related to the eating disorder, but an approach that adapts its focus depending also on the psychopathological pathway which has led to the development of the eating disorder.

Dissociation in eating disorders: relationship between dissociative experiences and binge-eating episodes

OBJECTIVE

Several findings support the hypothesis that there is a relationship between dissociation and eating disorders (EDs). The aims of this study were as follows: (1) to assess whether ED patients show a higher level of dissociation than healthy control (HC) individuals or psychiatric control patients with anxiety and mood disorders and (2) to investigate the effects of dissociation on ED symptoms, specifically binge eating behavior.

METHOD

Fifty-four ED patients, 56 anxiety and mood disorders control patients, and 39 HC individuals completed the Eating Disorder Examination Questionnaire and the Dissociation Questionnaire. Each participant was asked about the number of binge eating episodes he or she had experienced in the past 4 weeks.

RESULTS

The ED patients had higher levels of dissociation than both the psychiatric control group and the HC group. In the ED group, the number of binge episodes was related to the level of dissociation.

DISCUSSION

Dissociative experiences are relevant in EDs, and binge eating is related to dissociation. In patients affected by the core psychopathologic beliefs of EDs (overevaluation of shape and weight), dissociation may allow an individual to initiate binging behavior, thus decreasing self-awareness and negative emotional states, without having to deal with the long-term consequences of their actions.

The possible influence of impulsivity and dietary restraint on associations between serotonin genes and binge eating

Although serotonin (5-HT) genes are thought to be involved in the etiology of bulimia nervosa and binge eating, findings from molecular genetic studies are inconclusive. This may be due to limitations of past research, such as a failure to consider the influence of quantitative traits and gene-environment interactions. The current study investigated these issues by examining whether quantitative traits (i.e., impulsivity) and environmental exposure factors (i.e., dietary restraint) moderate 5-HT gene/binge eating associations in a sample of young women (N = 344). Binge eating was assessed using the Minnesota Eating Behavior Survey and the Dutch Eating Behavior Questionnaire (DEBQ). Impulsivity was assessed with the Barratt Impulsiveness Scale-Version 11. Dietary restraint was measured with a factor score derived from common restraint scales. Saliva samples were genotyped for the 5-HT2a receptor T102C polymorphism and 5-HT transporter promoter polymorphism. As expected, impulsivity and dietary restraint were associated with binge eating. Although the T allele of the 5-HT2a receptor gene and the s allele of the 5-HTT gene were associated with higher levels of impulsivity, there were no main effects of 5-HT genotypes on any binge eating measure, and interactions between genotypes, impulsivity, and dietary restraint were non-significant. In conclusion, we found no evidence to suggest that dietary restraint or impulsivity moderate associations between binge eating and these 5-HT genes. Future research should continue to explore interaction effects by examining larger samples, assessing dietary intake directly, and investigating other genes, traits, and environmental factors that may be related to binge eating and bulimia nervosa.

Validity and utility of the current definition of binge eating

OBJECTIVE

Binge eating, a cardinal symptom of bulimia nervosa (BN) and binge eating disorder (BED), continues to pose challenges in terms of its definition and thus construct validity and clinical utility. This article reviews the available empirical data that support or refute the current DSM-IV-TR defined characteristics of a binge episode.

METHOD

A systematic literature review was conducted using Medline/PubMed electronic database on DSM-IV-TR defined binge characteristics and associated attributes.

RESULTS

Data support the current DSM guidelines indicating that binge episodes typically occur in less than 2 h. Size of binge episodes has variability across BN and BED diagnostic groups. Loss of control (LOC) continues to be a core feature of binge eating. Negative affect is the most widely reported antecedent. Strikingly, little is known about binge episodes among individuals with anorexia nervosa-binge/purge subtype.

DISCUSSION

Available empirical evidence supports the current DSM duration and LOC attributes of a binge episode in BN and BED. However, a more controversial issues is the extent to which size is important in the definition of a binge episode (e.g., subjective vs. objective episodes) across diagnostic categories and the extent to which binge size informs prognosis, treatment, and clinical outcomes. Further study of binge eating attributes in AN is needed.

Confirmatory and exploratory factor analysis of the distress tolerance scale (DTS) in a clinical sample of eating disorder patients

A confirmatory factor analysis of the factor structure of the Distress Tolerance Scale (DTS) created by Corstorphine et al. [Corstorphine, E., Mountford, V., Tomlinson, S., Waller, G., & Meyer, C. (2007). Distress tolerance in the eating disorders. Eating Behaviors, 8, 91-97.] was conducted to assess whether the scale's purported three factors emerged in a clinical sample of patients with a DSM-IV diagnosed eating disorder. The original three-factor model was generally considered to be a poor fit for the data. Subsequent exploratory factor analysis indicated that a better fit emerged using a four-factor structure. Significant associations were observed between behavioral avoidance of positive affect and eating disorder psychopathology. Implications for use of the DTS with eating disorder patients are discussed.

Do schema processes mediate links between parenting and eating pathology?

OBJECTIVE

Adverse parenting experiences are commonly linked to eating pathology. A schema-based model of the development and maintenance of eating pathology proposes that one of the potential mediators of the link between parenting and eating pathology might be the development of schema maintenance processes--mechanisms that operate to help the individual avoid intolerable emotions.

METHOD

To test this hypothesis, 353 female students and 124 female eating-disordered clients were recruited. They completed a measure of perceived parenting experiences as related to schema development (Young Parenting Inventory-Revised (YPI-R)), two measures of schema processes (Young Compensatory Inventory; Young-Rygh Avoidance Inventory (YRAI)) and a measure of eating pathology (Eating Disorders Inventory (EDI)).

RESULTS

In support of the hypothesis, certain schema processes did mediate the relationship between specific perceptions of parenting and particular forms of eating pathology, although these were different for the clinical and non-clinical samples.

DISCUSSION

In those patients where parenting is implicated in the development of eating pathology, treatment might need to target the cognitive processes that can explain this link.

Evaluation of extinction as a functional treatment for binge eating

Binge eating is a serious behavior problem exhibited by individuals diagnosed with binge eating disorder and bulimia nervosa. Binge eating is thought to be maintained by automatic negative reinforcement in the form of relief from negative emotional responding. Current treatments produce only moderate abstinence, perhaps because they do not attempt to alter the functional consequences of the behavior. Although extinction has been thought impossible with behaviors maintained by automatic negative reinforcement, this study evaluated the application of extinction with binge eating. Four women who reported engaging in binge eating at least twice per week participated. Participants listened to an audio tape recording of the covert verbal behavior associated with their negative emotional responding during the binge to prevent alleviation of the negative emotional responding, thus eliminating the reinforcer in an attempt to reduce the behavior. The procedure effectively reduced frequency of the binges when correctly implemented. Implications and suggestions for future research are discussed.

Do chronic medical conditions increase the risk of eating disorder? A cross-sectional investigation of eating pathology in adolescent females with scoliosis and diabetes

PURPOSE

To investigate levels of eating pathology in female adolescents diagnosed with a chronic condition causing appearance change (adolescent-onset idiopathic scoliosis), a chronic condition affecting nutritional behavior (insulin-dependent diabetes mellitus), and healthy age-matched controls.

METHOD

Cross-sectional comparison of 192 females aged 11-19 years; 76 individuals diagnosed with scoliosis, 40 diagnosed with diabetes, and 76 control participants. Disordered eating behavior was quantified using the Eating Disorder Examination Questionnaire, and weight and body mass index (weight [kg]/height [m(2)]) measurements were taken for each participant.

RESULTS

The scoliosis group weighed less and had lower BMI scores (p < .001) than control participants. Of the participants with scoliosis, 25% were severely underweight, but only two met the behavioral criteria for anorexia nervosa; in others no association with disordered eating behaviour was found. Eating disorders were significantly more common (p < .05) in the diabetes participants than in the control group, with 27.5% of the group classified as having bulimia or binge eating disorder. All those classified as overweight or obese in the diabetes group were classified as pathological in terms of eating behavior.

CONCLUSIONS

The relationship between scoliosis and low body mass is a concern but is not a result of an eating disorder. Etiological mechanisms remain unclear and require further investigation. In the diabetes participants, bulimia and binge eating may prejudice effective condition management. Implications for successful adaptation, treatment intervention, and future research are discussed.

Subtyping adolescents with bulimia nervosa

Cluster analyses of eating disorder patients have yielded a "dietary-depressive" subtype, typified by greater negative affect, and a "dietary" subtype, typified by dietary restraint. This study aimed to replicate these findings in an adolescent sample with bulimia nervosa (BN) from a randomized controlled trial and to examine the validity and reliability of this methodology. In the sample of BN adolescents (N=80), cluster analysis revealed a "dietary-depressive" subtype (37.5%) and a "dietary" subtype (62.5%) using the Beck Depression Inventory, Rosenberg Self-Esteem Scale and Eating Disorder Examination Restraint subscale. The "dietary-depressive" subtype compared to the "dietary" subtype was significantly more likely to: (1) report co-occurring disorders, (2) greater eating and weight concerns, and (3) less vomiting abstinence at post-treatment (all p's<.05). The cluster analysis based on "dietary" and "dietary-depressive" subtypes appeared to have concurrent validity, yielding more distinct groups than subtyping by vomiting frequency. In order to assess the reliability of the subtyping scheme, a larger sample of adolescents with mixed eating and weight disorders in an outpatient eating disorder clinic (N=149) was subtyped, yielding similar subtypes. These results support the validity and reliability of the subtyping strategy in two adolescent samples.

Binge antecedents in bulimic syndromes: an examination of dissociation and negative affect

OBJECTIVE

We conducted a naturalistic study to examine negative affect and dissociative experiences as antecedents to binge episodes.

METHOD

Using handheld computers, 33 women with bulimic syndromes provided ongoing self-reports on eating behaviors, affects, and dissociative experiences over 7- to 29-day intervals.

RESULTS

Multilevel modeling analyses indicated that negative affect and dissociation were elevated prior to binge episodes. In addition, antecedent effects of dissociation on bingeing were independent of those attributable to negative affect.

CONCLUSION

Our results are consistent with models of binge eating that assign a causal role to negative mood and altered self-awareness. As such, our findings imply that binge eating is a multiply determined behavior linked to diverse cognitive and affective processes.

Difficulties regulating emotions: Do binge eaters have fewer strategies to modulate and tolerate negative affect?

The current study evaluated whether difficulties regulating emotions explained unique variance in binge eating and examined which types of emotion regulation difficulties are most strongly associated with binge eating. The Eating Disorders Diagnostic Scale and the Difficulties in Emotion Regulation Scale were completed by 695 undergraduates. Hierarchical regression results indicated that difficulties regulating emotions accounted for a significant amount of the variance in binge eating over and above sex, food restriction, and over-evaluation of weight and shape. Results also indicated that greater difficulty identifying and making sense of emotional states, and limited access to emotion regulation strategies were primarily responsible for the link between emotion regulation difficulties and binge eating. This supports a model of binge eating that includes emotional vulnerability and a deficit of skills to functionally modulate negative moods.

Relationships among attachment styles, personality characteristics, and disordered eating

OBJECTIVE

Insecure attachment styles and certain personality characteristics (i.e., high levels of neuroticism) have been associated with eating pathology. However, previous research has not examined these variables simultaneously and has not examined possible mediating relationships between attachment and personality characteristics for disordered eating. Because personality characteristics have emerged as some of the most robust predictors of disordered eating, it was predicted that the link between attachment and disordered eating might be through personality styles.

METHOD

Participants included 85 female twins and triplets who took part in the Michigan State University Twin Study. Disordered eating, attachment style, and personality characteristics were assessed. Hierarchical linear models were used to examine relationships among the variables.

RESULTS

Overall, neuroticism, and extraversion to a lesser extent, mediated the relationship between insecure-resistant attachment and disordered eating. Specifically, higher scores on the neuroticism scale predicted more disordered eating and explained the relationship between insecure-resistant attachment and disordered eating.

CONCLUSION

These results suggest that relationships between attachment style and disordered eating are indirect, in that neuroticism fully mediates associations between insecure-resistant attachment and disordered eating.

Development of a measure to assess invalidating childhood environments in the eating disorders

OBJECTIVE

The role of childhood abuse is well recognised within the eating disorders. However, the impact of parental invalidation of the child's emotional needs has not been investigated. Such invalidation is potentially important because it appears to be associated with the difficulties in tolerating distress that are often seen in adults with eating disorders. This study aims to develop a measure of childhood invalidating environments (Invalidating Childhood Environments Scale; ICES). It also investigated the relationship between childhood experiences, levels of distress tolerance and eating pathology.

METHOD

Seventy-three eating-disordered women and 62 non-eating-disordered women completed a newly developed measure of invalidating environments (ICES), the Eating Disorders Inventory, and a Distress Tolerance Scale.

RESULTS

The ICES had acceptable psychometric and clinical validity. Women who scored highly on the ICES had greater levels of eating disturbance. Within the clinical sample, the data were compatible with a model where difficulties in tolerating distress partially mediate the relationship between perceived invalidation by the father and eating pathology.

CONCLUSIONS

Parental invalidation is a potentially important construct in the eating disorders. This paper demonstrates that the ICES is a valid measure of that construct. This study suggests a clear framework for working with patients, where evidence of an invalidating childhood environment indicates a need to work with patients on their capacity to tolerate distress.

Distress tolerance in the eating disorders

OBJECTIVE

It is commonly noted that patients with eating disorders have difficulties in regulating emotional states. This construct is similar to the concept of distress tolerance, which has been identified as a problem in patients with impulsive disorders. However, the elements that make up distress tolerance are not clearly delineated, making it difficult to target treatment in relevant cases. This study aimed to develop a measure of distress tolerance, and to validate it clinically with the eating disorders.

METHOD

The sample consisted of 72 women with DSM-IV eating disorder diagnoses, and 62 women with no history of eating disorders. Each completed a newly developed measure of distress tolerance (the Distress Tolerance Scale; DTS) and the Eating Disorders Inventory.

RESULTS

The DTS was made up of three scales, each with acceptable psychometric properties. Two of those scales differentiated the groups--the clinical women showed higher levels of 'Avoidance of affect', while the non-clinical women had higher scores in the 'Accept and manage' scale. Avoidance of affect was positively associated with unhealthy eating attitudes.

CONCLUSIONS

It is important to examine both maladaptive and adaptive means of coping with affect in the eating disorders. Treatment strategies for modification of distress tolerance should address both the reduction of avoidance and the development of emotional management skills. Further research is needed to determine whether these findings are relevant to the presence of other impulsive behaviours in the eating disorders.

Affektregulatorische Funktion der Binge-Episode bei Bulimia nervosa und Binge Eating Störung

Zusammenfassung. Theoretischer Hintergrund: Die Rolle der Affektregulation bei der Aufrechterhaltung bulimischer Essanfälle und kompensatorischer Verhaltensweisen ist geprägt durch ein heterogenes Forschungsfeld. Der Vergleich dieser affektregulatorischer Funktionen zwischen bulimischen Patientinnen und Patientinnen mit einer Binge Eating Disorder (BED) fehlt weitgehend. Fragestellung: Die Studie untersucht die Frage, ob ein Essanfall zu einer Zunahme negativer Affekte führt, und ob diese Zunahme durch das Abführen wieder reduziert wird. Zusätzlich wird untersucht, inwieweit die Zunahme der negativen Affekte für die bulimischen Patienten spezifisch ist. Methode: Die differentielle Affektskala wird in einem problemanalytischen Explorationssetting zu Essanfällen und Episoden des Erbrechens bei 27 stationär behandelten bulimischen Patientinnen und 21 Patientinnen mit BED eingesetzt. Ergebnisse: Die bulimischen Patientinnen berichten im Vergleich zu den BED Patientinnen nach einem Essanfall eine Zunahme von Scham, Schuld, Ekel und Verachtung bei gleichzeitiger Reduktion von Interesse. Die BED Patientinnen berichten nur einen Anstieg von Schuld. Für die bulimischen Patientinnen reduziert das Erbrechen die erlebte Angst und den Ekel und führt außerdem zu einer Zunahme an Freude.

Changes in internal states across the binge-vomit cycle in bulimia nervosa

While there is considerable evidence that bulimic behaviors serve the function of modifying internal states (e.g., satiety, mood), there is less clarity over the roles of the different behaviors across the binge-purge cycle. The present study examines the impact of bingeing and vomiting upon these internal states at different time points, and evaluates the potential reinforcement of those behaviors by the changes in internal states. Twenty-three women with diagnoses of bulimia nervosa completed a diary of all binge-vomit episodes over the course of 7 days, rating their internal states (satiety, negative mood, positive mood) at four time points during each episode. There were substantial changes across the cycle in levels of hunger, fullness, guilt/shame, anxiety/worry, and happiness/relief, but not in other states. The changes indicate that the binge-vomit cycle is maintained by the effects of both behaviors, but that the vomiting behavior evokes the strongest pattern of reinforcement. Further research is needed to determine the levels of internal states during the binge itself.

Effect of sibutramine and of cognitive-behavioural weight loss therapy in obesity and subclinical binge eating disorder

AIM

In this randomized, double-blind, placebo-controlled study, the effect of sibutramine and cognitive-behavioural weight loss (cognitive-BWL) treatment was assessed in obese subjects with and without subclinical binge eating disorder (sBED).

METHODS

Seventy-three obese participants were recruited from the community, 29 with and 44 without sBED. Subjects were randomly assigned to a 16-week treatment with either sibutramine or placebo while simultaneously participating in a cognitive-behavioural weight loss treatment.

RESULTS

Intent-to-treat analysis showed moderate weight loss after treatment in all subject groups. Treatment with BWL programs and sibutramine leads to a higher weight loss in all subjects compared with that in patients who had undergone BWL programs alone. Subjects with sBED significantly reduced their binge episodes during treatment, but with no augmenting effect of sibutramine.

DISCUSSION

Our results yield further evidence that sBED is associated with characteristics comparable with full-syndrome BED, significantly differing from those of obesity alone. These findings call for a systematic assessment of eating behaviour before starting obesity treatment.

The phenomenology of food cravings: The role of mental imagery

The study aimed to investigate the role of mental imagery in the experience of food cravings. A sample of 130 undergraduate students was first asked to recall and rate a previous food craving experience. Second, they were asked to imagine themselves eating their favourite food and to rate the involvement of different sensory modalities. It was found that mental imagery was a key element in both the retrospective craving experience and the current food induction. In particular, craving intensity was related to the vividness of the food image (r = .46). The specific sensory modalities most involved were visual (39.7%) and gustatory (30.6%), followed by olfactory (15.8%). There was little involvement of auditory or tactile modalities. It was concluded that cognitive experimental techniques aimed at reducing the vividness of visual, gustatory or olfactory imagery, might usefully be deployed to reduce unwanted food cravings.

Assessing the functional nature of binge eating in the eating disorders

This study explored the functional nature of binge eating through the development of a new self-report instrument called the Binge Eating Adjective Checklist. Participants were 405 adult females who presented to a specialized eating disorders clinic. A subset of participants with bulimia nervosa also completed additional psychometrics and treatment. Those participants who reported greater reductions in negative affective and somatic states during a binge episode were also more distressed on measures of perfectionism, self-esteem, ineffectiveness, and interceptive awareness. They were also less likely to achieve abstinence from bingeing and vomiting over the course of treatment. Thus, the instrument appears to offer a methodology for studying the phenomenology of binge eating and the prediction of therapeutic outcome in bulimia nervosa.

Cognitive avoidance in the strategic processing of ego threats among eating-disordered patients

BACKGROUND

This study of strategic processing examined whether it is possible to demonstrate cognitive avoidance of ego threats in women with eating disorders, using a task that involves less automatic identification of threat cues.

METHOD

Fifty eating-disordered (anorexic and bulimic) and 50 comparison women completed a task of strategic processing, assessing their speed of solving neutral, food-related, and ego threat-related anagrams.

RESULTS

Cognitive avoidance of threat-related information was shown, but only among women with bulimic characteristics. The presence of bulimic behaviors (binging and vomiting) was the clearest factor associated with such avoidance. There was no evidence of avoidance of disorder-related (food) cues.

DISCUSSION

Research and therapeutic implications are discussed, including the potential utility of therapies that directly or indirectly address the schema-level representation of ego threats when working with eating pathology.

The impact of subliminal abandonment and unification cues on eating behavior

BACKGROUND

Subliminal presentation of visual abandonment cues leads to greater levels of eating, despite a lack of conscious awareness of the information involved. The current study examined whether this behavioral impact can be countered by the subliminal presentation of contradictory, counterschematic information (unification cues).

METHOD

Ninety-six nonclinical women were presented with subliminal abandonment cues, either preceded or followed by neutral or unification cues. The dependent variable was the amount eaten after the task.

RESULTS

Presenting subliminal unification information before or after the subliminal abandonment cue significantly reduced the amount eaten (relative to the impact of neutral cues).

DISCUSSION

These findings are consistent with a model where preconscious processing of unification cues has the effect deactivating abandonment schemas, either through inoculation or restoration. Preconscious presentation of unification cues might play a role in the broader cognitive-behavioral treatment of bulimic behaviors.

Cognitive-behavioral theories of eating disorders

This article presents an integrated cognitive-behavioral theory of eating disorders that is based on hypotheses developed over the past 30 years. The theory is evaluated using a selected review of the eating disorder literature pertaining to cognitive biases, negative emotional reactions, binge eating, compensatory behaviors, and risk factors for eating disorders. In general, hypotheses derived from cognitive-behavioral theories have been supported by a variety of research studies. The implications of these findings for treatment and prevention of eating disorders are discussed. This review of the literature serves as a conceptual base for some of the other articles that are included in this special issue of Behavior Modification. The article concludes with an introduction to six articles that discuss issues related to psychiatric classification, assessment, treatment, and prevention of eating disorders.

Time course of symptom remission in eating disorders

OBJECTIVE

The study was carried out to test whether time to remission varies for different eating disorder symptoms.

METHOD

Sixty-five patients (35 anorexic patients and 30 bulimic patients) treated with psychotherapy were interviewed 2 1/2 years after initial assessment.

RESULTS

The anorexic physical symptoms remitted before the psychological symptoms of anorexia and bulimia nervosa, as did the bulimic behaviors: binging and purging. Nonpurging compensatory behavior and obsession with weight and shape were the last symptoms to remit. Differences between the anorexic and bulimic groups were found between the remission order of psychological symptoms.

DISCUSSION

In spite of different treatments and symptoms between patients, the results support the notion of a common pattern in the process of change including a long and stepwise course. The results detail a template of the course to recovery for eating disorders.

Reduction of food cravings through concurrent visuospatial processing

OBJECTIVE

Two experiments adopted a working memory approach to evaluate the effectiveness of visuospatial tasks as a technique for reducing food cravings.

METHOD

Dieting and non-dieting women were asked to form images of both food-related and nonfood items, induced by either pictures (Experiment 1) or verbal cues (Experiment 2). They were required to concurrently perform one of three tasks that load on the visuospatial sketch pad of working memory: saccadic eye movements, dynamic visual noise, or spatial tapping.

RESULTS

In support of the working memory model of limited visuospatial capacity, concurrent visuospatial activity reduced the vividness of food-related images which, in turn, reduced the intensity of the associated craving. The same pattern of results was observed across dieters and non-dieters and for all stimulus types.

DISCUSSION

Visuospatial tasks may provide a useful technique for the treatment of food craving episodes in both nonclinical and clinical populations.

Negative mood-induced overeating in obese binge eaters: an experimental study

OBJECTIVES

To test the hypotheses that induction of negative mood in obese binge eaters would increase food intake, and that this would be greatest in those who were highly restrained.

DESIGN

Experimental manipulation of mood (neutral vs sad film) prior to the presentation of food in a taste test.

PARTICIPANTS

A total of 40 obese female binge eaters (41.7 y, mean BMI=40.2 kg/m(2)).

MEASURES

Visual analogue assessment of mood and hunger motivation, dietary restraint (Dutch Eating Behaviour Questionnaire), and food intake.

RESULTS

Exposure to the sad film resulted in a significant decrease in mood for both restrained and unrestrained participants. Those in the negative mood condition ate significantly more food, and the restrained eaters consumed the most. However, the expected restraint by mood interaction just failed to reach significance (P=0.06)

CONCLUSIONS

The salience of negative mood in promoting overeating was confirmed. Conversely, dietary restraint had no significant impact on food intake. Further experimental work on binge eating in this group would be of value in clarifying the role of dieting and informing treatment approaches.

Socially driven eating and restriction in the eating disorders

The aims of this study were: to develop a measure to examine the relationship between socially driven eating and specific eating behaviours; to examine whether different social situations increase or decrease eating in different diagnostic groups; and to determine whether dimensional links exist between responses to social triggers and different aspects of eating pathology. A clinical group of 107 eating-disordered women and 143 nonclinical women completed a measure of socially driven eating and restriction (the Social Eating Scale, or SES) and the Eating Disorders Inventory. The SES had good psychometric properties. Patients with binge-eating disorder (BED) ate more in all social situations, while those with anorexia nervosa ate less. In contrast, bulimia nervosa (BN) patients ate more in general social situations but less in situations where the social trigger was related to food, shape, or weight. There were consistent dimensional links between responses to social triggers and different aspects of eating pathology. These findings support the recent literature on social triggers of eating behaviours but stress the relevance of the mixed pathology of women with BN. The role of social triggers for eating might help to explain the effectiveness of interpersonal psychotherapy when applied to the eating disorders.

An evaluation of affect and binge eating

The affect regulation model of binge eating suggests that binge eating occurs because it provides momentary relief from negative affect. The purpose of this study was to evaluate change in affect during binge eating to evaluate the merits of this model. Participants were young adult women from a midwestern university. Binge eaters recorded their level of pleasantness using the affect grid at 2-minute intervals before, during, and after binge eating episodes and regular meals. Controls recorded in a similar manner during meals. The results showed a different pattern of affect for binge eaters during binge eating episodes and normal meals and for binge eaters and controls at normal meals. The results support the affect regulation model of binge eating and suggest that binge eating is negatively reinforced because it produces momentary relief from negative affect.

Dropout from brief psychotherapy within a combination treatment in bulimia nervosa: role of personality and anger

BACKGROUND

To explore the personality, psychopathology, and clinical features of bulimic patients who do not complete psychotherapy, within a combined treatment.

METHODS

86 patients with bulimia nervosa (BN; DSM-IV) were evaluated before beginning treatment. The Eating Disorder Inventory II (EDI-II), State-Trait Anger Expression Inventory (STAXI), and the Temperament and Character Inventory (TCI) were administered to all patients.

RESULTS

3 subjects failed to engage in psychotherapy. Comparing patients who dropped out (n = 28) with those who did not drop out from psychotherapy (n = 55), significant differences were found in some psychopathologic (EDI-II, STAXI) and personality (TCI) variables. In particular, patients who dropped out from the treatment were more impulsive and more likely to feel anger; they were also less cooperative and less self-directive. No significant differences in sociodemographic, clinical variables and in response to fluoxetine were found between the two groups (dropout and completers).

CONCLUSIONS

We found a characteristic profile in the bulimic patients who dropped out from brief psychotherapy, i.e., they are less cooperative and more predisposed to anger. These data suggest that dropping out in a subgroup of BN patients could be related to borderline personality traits and to difficulties in making and maintaining a therapeutic relationship. Implications for treatment are discussed.

Functional analysis of problem behavior: a review

Functional analysis methodology focuses on the identification of variables that influence the occurrence of problem behavior and has become a hallmark of contemporary approaches to behavioral assessment. In light of the widespread use of pretreatment functional analyses in articles published in this and other journals, we reviewed the literature in an attempt to identify best practices and directions for future research. Studies included in the present review were those in which (a) a pretreatment assessment based on (b) direct observation and measurement of (c) problem behavior was conducted under (d) at least two conditions involving manipulation of an environmental variable in an attempt (e) to demonstrate a relation between the environmental event and behavior. Studies that met the criteria for inclusion were quantified and critically evaluated along a number of dimensions related to subject and setting characteristics, parametric and qualitative characteristics of the methodology, types of assessment conditions, experimental designs, topographies of problem behaviors, and the manner in which data were displayed and analyzed.

Functional assessment of binge eating in a clinical sample of obese binge eaters

The aim of this study was to assess the antecedents and consequences of binge eating in ten obese binge eaters. The subjects completed retrospective measures and monitored themselves at the time binge eating occurred. The results show that the common temporally remote antecedents to binge eating included being very busy throughout the day, feeling unusually tired/fatigued, having consumed too much food during the day, and feeling down or irritable. A number of affective variables (e.g., anxiety, anger, frustration, sadness, guilt, agitation) temporarily decreased during a binge eating episode, yet increased again following binge eating. Furthermore, the antecedents and consequences surrounding binge eating episodes were moderately to highly variable both between and within subjects, thus supporting the need for individualised functional assessments of the antecedents and consequences of binge eating. The implications for treatment and future research are discussed.

Excessive exercise in anorexia nervosa and bulimia nervosa: relation to eating characteristics and general psychopathology

OBJECTIVE

Excessive exercise is a well-known phenomenon in anorexia nervosa, but less is known about its role in bulimia nervosa. In addition, there is little evidence regarding the psychopathological processes that might act as predisposing, triggering, or maintaining factors for such exercise. The present study examined the presence of excessive exercise in different women with eating disorders, and its psychopathological correlates.

METHODS

Case notes from 63 anorexia nervosa and 61 bulimia nervosa patients were examined. Two-way multivariate analyses of variance (diagnosis x use of excessive exercise) were used to determine the impact of the two factors upon eating characteristics (EAT-40 and BITE) and psychopathological symptoms (SCL-90-R).

RESULTS

While high levels of depression were more likely among all patients who used excessive exercise, levels of anxiety and somatization were particularly high only among those anorexics who exercised excessively.

DISCUSSION

Possible explanatory models are advanced to account for this pattern of findings, focusing on the possible use of exercise as an affect regulation strategy among anorexia nervosa patients. Further research is suggested to test and develop this model, and possible clinical implications are outlined.

Disordered eating behaviors and reward sensitivity

This research evaluated the extent to which reward sensitivity demonstrated associations with binge and purge behavior frequency. A verbal operant conditioning task designed to assess conditionability to reward cues was administered to a sample of 34 women who exhibited disordered eating patterns for at least I month prior to study participation. Reward sensitivity significantly correlated with the average weekly frequency of purge (r = 0.44) but not binge behaviors. These findings suggest that reward sensitivity has some associations with aspects of disordered eating and therefore may have relevance for theories on the maintenance of some forms of eating disorder-related behavior.

Bulimics' responses to food cravings: is binge-eating a product of hunger or emotional state?

This study examined the roles of hunger, food craving and mood in the binge-eating episodes of bulimic patients, and identified the critical factors involved in the processes surrounding binge-eating episodes that follow cravings. This was a prospective study of the binge-eating behaviour of 15 women with bulimia nervosa. The participants used food intake diaries and Craving Records to self-monitor their nutritional behaviour, hunger levels and affective state. Cravings leading to a binge were associated with higher tension, lower mood and lower hunger than those cravings not leading to a binge. Levels of tension and hunger were the critical discriminating variables. The findings of the study support empirical evidence and models of emotional blocking in binge-eating behaviour and challenge the current cognitive starve-binge models of bulimia. The role of food cravings in the emotional blocking model is discussed in terms of a classically conditioned motivational state. Implications for treatment are addressed.

Internal and external antecedents of binge eating episodes in a group of women with bulimia nervosa

OBJECTIVE

This research examined the internal and external factors that predict whether a food craving develops into a binge in bulimia nervosa.

METHOD

Fifteen bulimic women kept diary records of food cravings over the course of a week, noting their internal state, environmental triggers, and whether the craving developed into a binge. Eighty cravings were examined, of which approximately one half developed into binges.

RESULTS

At the bivariate level, binge eating resulted from cravings more often if the women were alone, in the morning, and following eating the craved food. These factors interacted, so that binges were more likely if the women avoided a craved food in the morning, but not later in the day.

CONCLUSIONS

These findings support a model of binge eating for which both internal states (craving, eating the craved food) and external factors (time of day, social circumstances) need to be taken into account. Relevant models of craving are discussed, along with their implications for clinical practice.

Anger and bulimic psychopathology among nonclinical women

OBJECTIVE

Although there are well-established links between bulimic psychopathology and some affective states, the role of anger is not clearly understood. This is likely to be a product of the diverse nature of anger. The present study examines the association of different components of anger with bulimic attitudes and behaviors among a nonclinical group of women.

METHODS

Eighty-three nonclinical women completed standardized measures of anger and bulimic attitudes/behaviors.

RESULTS

Bulimic attitudes and behaviors were correlated specifically with state anger and anger suppression, rather than with trait anger. The pattern of results suggests that binging and vomiting behaviors may serve different functions with regard to anger.

CONCLUSIONS

Bulimic attitudes and behaviors appear to reduce immediate anger states, particularly when the individual has a strong tendency to avoid expressing that emotion. Potential therapeutic implications are considered.

Childhood emotional abuse and eating psychopathology

The potential role of childhood emotional abuse (CEA) in the etiology and maintenance of eating psychopathology is reviewed. While childhood sexual and physical abuse have been hypothesized as risk factors in multifactorial models of eating disorders, a role for CEA has only recently been considered. Initial findings demonstrate a phenomenological link between CEA and eating psychopathology, and suggest that this association might be different to the links for other forms of trauma (i.e., CEA may have a relationship with a broader range of eating symptoms than sexual and physical abuse). However, the psychological processes that might account for such a link are not yet well understood. Potential cognitive and affective mediators are considered, with a particular emphasis upon low self-esteem and anxiety. A model is proposed, to act as a framework for further research into this field. The clinical implications of the research to date and of the proposed model are discussed.

Cognitive content among bulimic women: the role of core beliefs

OBJECTIVE

Most cognitive analyses of bulimic disorders have stressed the role of negative automatic thoughts or dysfunctional assumptions regarding weight, shape, and food. This study considered the role of more general core beliefs in the cognitive content of bulimic disorders.

METHODS

Fifty bulimic and 50 comparison women completed the Schema Questionnaire (YSQ) and a diary measure of bulimic behaviors.

RESULTS

The groups could be differentiated using just three of the beliefs: perceived Defectiveness/Shame, Insufficient Self-Control, and Failure to Achieve. This discrimination included differences between bulimic subgroups. At the symptomatic level, the bulimic women's Emotional Inhibition beliefs predicted their severity of binging, whereas their Defectiveness/Shame beliefs predicted severity of vomiting.

CONCLUSIONS

The findings support a model of bulimic psychopathology where the central cognitions encompass more than beliefs about food, shape, and weight. Clinical implications are considered.

Cognitive avoidance and bulimic psychopathology: the relevance of temporal factors in a nonclinical population

OBJECTIVE

Previous research has provided evidence of both an attentional bias towards, and a cognitive avoidance of threat cues, by individuals with unhealthy eating attitudes and disorders. It has been suggested that an initial attentional bias might be followed by a later avoidance process. The present study assessed the speed of processing of self-directed ego threat words following different interstimulus intervals (500, 1,000, 1,500, and 2,000 ms).

METHOD

Fifty female students completed a computer-driven threat processing task and the Eating Disorders Inventory.

RESULTS

Women were significantly slower to process ego-self threat cues following the 2, 000-ms interval than following the other intervals (500, 1,000, and 1,500 ms). Those women with increased levels of bulimic attitudes were slower to process threats following the 1,500-ms interval, but not after the longer or shorter intervals.

CONCLUSIONS

The results stress the importance of temporal factors in the processing of threat by individuals with high levels of eating psychopathology. The findings are discussed in terms of an appropriate cognitive model.

Subliminal activation of abandonment- and eating-related schemata: relationship with eating disordered attitudes in a nonclinical population

OBJECTIVE

Previous research has demonstrated that subliminal abandonment cues can facilitate eating behavior. It is believed that such eating is a response to the activation of specific core schemata. However, the precise nature of those schemata has not been established. This study examined whether the presentation of subliminal abandonment and food/shape cues results in the activation of abandonment-related or food-related schemata.

METHOD

Eighty-two women were exposed to one of three subliminal cues- an abandonment cue ("lonely"), an appetitive cue ("hungry"), and a neutral cue ("gallery"). They subsequently completed Stroop tasks to measure activation of relevant schemata.

RESULTS

Subliminal presentation of abandonment cues led to the activation of food- and shape-related schemata. In contrast, subliminal appetitive cues resulted in an activation of abandonment-related schemata.

CONCLUSIONS

The results show preliminary support for a multilevel cognitive model, involving indirect links between subliminal cue type and the activation of eating-related cognitions.