Binge eating as escape from self-awareness

The effect of hypothalamic peptide YY on hippocampal acetylcholine release in vivo: implications for limbic function in binge-eating behavior

Central injection of peptide YY (PYY) in sated rats produces the most powerful stimulating effect of food intake known to date. The neural mechanisms by which PYY regulates appetite are not clear but may be important because abnormal levels of PYY have been implicated in the neurobiology of bulimia nervosa. Interactions between brain acetylcholine (ACh) and PYY had not been studied. Therefore, the present experiments were designed to explore the in vivo release of ACh from the hippocampus (HPC) of rats in response to hypothalamic infusion of PYY. Hippocampal ACh release was found to increase 400% in response to 10 microg PYY. In a separate experiment, blockade of the same area of the HPC with bilateral intracerebral injections of 3.5 microg scopolamine did not affect intake stimulated by intrahypothalamic injection of 4 microg PYY. Furthermore, a third experiment showed, for the first time, that PYY (2.5-10.0 microg) can elicit robust feeding when infused directly into the HPC. The significance of these findings to the activation of limbic functions such as memory, reinforcement, and obsessional processes that accompany human binge-eating syndromes is discussed.

Enhancing motivation for change in treatment-resistant eating disorders

Denial and resistance to change are prominent features in most patients with anorexia nervosa. The egosyntonic quality of symptoms can contribute to inaccuracy in self-report, avoidance of treatment, difficulties in establishing a therapeutic relationship, and high rates of attrition and relapse. Individuals with bulimia nervosa are typically more motivated to recover, but often ambivalent about forfeiting the ideal of slenderness and the protective functions of binge-purge behavior. Few attempts have been made to assess denial and resistance in the eating disorders, or to examine alternative strategies for enhancing motivation to change. Review of the clinical literature indicates a striking convergence of recommendations across conceptually distinct treatment approaches. Clinicians are encouraged to acquire a frame of reference that can help them understand the private experience of individuals with eating disorders, empathize with their distress at the prospect of weight gain, and acknowledge the difficulty of change. The Socratic method seems particularly well-suited to work with this population because of its emphasis on collaboration, openness, curiosity, patience, focused and systematic inquiry, and individual discovery. Four themes are crucial in engaging reluctant eating-disordered clients in therapy: the provision of psychoeducational material, an examination of the advantages and disadvantages of symptoms, the explicit use of experimental strategies, and an exploration of personal values.

To eat or not to eat: affective and physiological mechanisms in the stress-eating relationship

The current study aggregated methods from the cardiovascular reactivity and dietary restraint paradigms in an attempt to advance our understanding of stress-induced eating behavior. Seventy-seven female subjects completed a protocol consisting of distinct baseline, stress-induction, and recovery phases during which we monitored blood pressure, heart rate, and self-reported affect. Food was inconspicuously made available to participants during the recovery phase. Our results replicated the restraint x affect level interaction observed in the restraint literature, while showing that physiological measures could further explain distressed eating behavior. Physiological arousal was found reliably to predict reduced food consumption, but only among unrestrained eaters. Analysis of the recovery data showed that food consumption was associated with impaired physiological recovery rates for restrained but not for unrestrained participants. We believe that our results help to reconcile findings in the stress, eating, and dietary restraint fields and offer support for recently developed theories of stress-induced overeating.

Eating behavior following stress in women with and without bulimic symptoms

OBJECTIVE

This study examined the effects of an interpersonal stressor on subsequent calorie intake in females with (N = 20) and without (N = 20) significant bulimic symptomatology.

METHOD

Subjects participated in two laboratory sessions that differed according to experimental condition (stress versus no stress), completed self-report measures of mood and anxiety before and after the experimental task, and were provided with an array of snack foods after each session.

RESULTS

Counter to the hypothesis, women with bulimic symptoms did not differentially increase their intake when exposed to stress. However, results for the intake of each macronutrient indicated that both bulimic and control women increased their consumption of carbohydrates following the stressor. Thus, stress was related to increased carbohydrate consumption by all subjects but did not differentially affect the consumption of women with bulimic symptoms.

CONCLUSIONS

It may be that women with bulimic symptoms are not differentially vulnerable to eating in response to stress or that current laboratory paradigms are unable to detect differences in eating following a stressor.

Impact of a history of physical and sexual abuse in eating disordered and asymptomatic subjects

The present study aimed to explore the impact of sexual and/or physical abuse among eating disordered patients (ED) and asymptomatic subjects. A total of 86 patients with anorexia nervosa, 69 patients with bulimia nervosa and 81 asymptomatic subjects were assessed. Among ED, we did not find a significant association between abuse experiences and the severity of the eating disorder, or between abuse and dissociative symptoms. Among ED, self-destructive behaviour appears to be the most important predictor of a history of sexual and/or physical abuse. In contrast, in the asymptomatic group, the score on the Dissociation Questionnaire is the only significant predictor of reported abuse experiences.

Further support for consistent self-monitoring as a vital component of successful weight control

OBJECTIVE

This study attempted to replicate that of Baker and Kirschenbaum by providing a descriptive analysis of the relationship between self-monitoring and weight control.

PROCEDURES

Fifty-nine women and men in long-term cognitive-behavioral treatment for obesity participated over an 8-week period. Percentages of participants who self-monitored consistently and the relationship between the variability in self-monitoring and weight change were examined.

RESULTS

As in the previous study, a substantial minority of the participants in this research (26.3%) self-monitored all foods eaten on less than half of the days evaluated. The assertion of Baker and Kirschenbaum that self-monitoring is most appropriately viewed as both a state and a trait was supported by finding that the most consistent self-monitors lost more weight than the least consistent self-monitors; however, regardless of overall self-monitoring consistency, participants lost much more weight during their two most consistent weeks compared with their two least consistent weeks. Again, as in the previous study, only the more consistent quartile of self-monitors lost a substantial amount during the course of this study.

DISCUSSION

The results of both studies taken together suggests that a reasonable target for consistency for self-monitoring within the context of a professional cognitive-behavioral treatment program may be self-monitoring all foods eaten on at least 75% of the days. If participants generally self-monitor on less than half of the days during participation in such programs, they may be very unlikely to succeed at weight loss both during the program and afterward.

Test of Stice's dual pathway model: dietary restraint and negative affect as mediators of bulimic behavior

The present study was designed to test whether dietary restraint and negative affect mediate the relationship between body dissatisfaction and bulimic behavior. Four hundred and twelve female students completed questionnaires which measured body dissatisfaction, restrained eating, negative affect and bulimic behavior. The results indicated that dietary restraint and negative affect partially mediated the relationship between body dissatisfaction and bulimic behaviors. The findings are discussed in light of previous research which suggests that restraint needs to be viewed as a multidimensional construct. Longitudinal studies are now needed to investigate the causal and possible bidirectional nature of the interrelationships in the model tested here.

Relationship of childhood sexual abuse and eating disorders

OBJECTIVE

To review the literature that has examined the relationship between childhood sexual abuse and the eating disorders.

METHOD

Each of the five authors reviewed all identified empirical studies to be certain that inclusion/exclusion criteria were met. Two teams of raters then independently reviewed each study to determine whether it supported any of a series of six hypotheses that had been tested in this literature.

RESULTS

This review indicates that childhood sexual abuse is a nonspecific risk factor for bulimia nervosa, particularly when there is psychiatric comorbidity. There is some indication that childhood sexual abuse is more strongly associated with bulimic disorders than restricting anorexia, but it does not appear to be associated with severity of the disturbance.

CONCLUSION

Childhood sexual abuse is a risk factor for bulimia nervosa with significant comorbidity. Further study of the nature of this relationship is warranted.

Effects of negative outcome on food consumption in college women with and without troubled eating patterns

This study looked at the effects that failure experiences have on food consumption and their effect on college women. Part I of the study (N = 169) was used to screen subjects for Part II (N = 55) based on scores on the Bulimia Test-Revised. In part II, eating-disordered and control participants completed one of two types of tasks-a negative outcome and a neutral outcome control task. Following the task, a bogus cookie rating task provided the opportunity for participants to eat chocolate chip cookies. Mood was assessed throughout Part II. Results indicate that mood was more negative following the negative outcome task. Eating-disordered participants ate more than did controls in this same condition; these participants also reported improved mood after eating.

Esteem Threat, Self-Regulatory Breakdown, and Emotional Distress as Factors in Self-Defeating Behavior

Patterns of human self-defeating or self-destructive behavior are examined in relation to several hypothesized causes. Threatened egotism appears to be a major, pervasive cause: Self-defeating responses are especially common when people feel that others may perceive them less favorably than the people desire. Self-regulation failure is also a common element in most self-defeating behavior. Emotional distress is often a precipitating factor. Several causal processes, including foolish risk taking and escapist responses, link emotional distress to self-defeat.

Functional assessment and binge eating. A review of the literature and suggestions for future research

This article briefly discusses the process of conducting a functional assessment of a problem behavior. Current research on the assessment of antecedents and consequences of binge eating behavior is then reviewed. The article concludes with suggestions for future research in the functional assessment and classification of binge eating.

Effects of suppressing the urge to drink on the accessibility of alcohol outcome expectancies

Previous work has shown that attempts to deliberately suppress a given thought is associated with heightened accessibility of thought-related information both during and following suppression (Wegner, 1994, Psychological Review, 101, 34-52). This study examined whether attempts to suppress the urge for alcohol would similarly be associated with heightened accessibility of alcohol-related information. Heavy social drinkers were exposed to the sight and smell of their usual alcoholic beverage either under the instructions to suppress their urge to drink alcohol or without such instruction. Following this task, participants were asked to make timed judgements about the applicability of a series of alcohol outcome expectancies. Results supported the view that suppression increases the accessibility of information in memory. Those in the Suppression condition were faster to endorse alcohol outcome expectancies following the exposure to alcohol cues than those in the Control condition. Findings are discussed in terms of cognitive strategies for regulating alcohol use and patterns of restrained drinking.

The aversiveness of specific emotional states associated with binge-eating in obese subjects

OBJECTIVE

The aim of this study was to examine the hypothesis that non-purge-related binge-eating in obesity is maintained by a 'trade-off' in which a highly aversive emotional state is exchanged for a less aversive state.

METHOD

Ninety-eight obese binge-eaters meeting the DSM-IV criteria for binge-eating disorder were contrasted with 65 non-binge-eating controls on their perceived distress associated with negative mood states usually experienced before and after binges.

RESULTS

Binge-eaters reported significantly greater distress and lower tolerance of negative mood compared to controls. Furthermore, when compared with controls, binge-eaters reported that emotions typically reported before binges (e.g. anger) were more aversive than those reported after (e.g. guilt).

CONCLUSIONS

These results were interpreted as supporting the 'trade-off' theory and have implications for the treatment of binge-eating disorder.

Biases in the processing of different forms of threat in bulimic and comparison women

This study uses Stroop methodology to investigate cognitive biases in the processing of five different forms of threat in bulimic and comparison women. The processing of different forms of threat was found to be relatively independent, which suggests that the measures do not tap a unitary threat construct. As predicted, the bulimic women showed a greater general attentional bias (interference effect) than the comparison women in color-naming threatening words. In the bulimic women, an attentional bias for specific forms of threat was positively correlated with bulimic psychopathology. A strong association was found between bulimic characteristics and sensitivity to self-directed ego-threats and a less robust association with sensitivity to autonomy threats (threats to personal control). The clinical implications of these findings are discussed in light of recent formulations of bulimia, which suggest that a function of binging and vomiting is to reduce the individual's awareness of threat (e.g., aversive emotional states).

Psychotherapy and bulimia nervosa: evaluation and long-term follow-up of two conflict-orientated treatment conditions

Analytic in-patient therapy (n = 32) and systemic out-patient therapy (n = 39) were applied to patients with bulimia nervosa, and the effects were evaluated 14, 26 and 38 months after the start of the treatments. Our assumptions about the general efficacy of both conflict-orientated techniques were confirmed: both therapies satisfactorily reduced the symptomatic behaviour, as well as secondary factors related to bulimia nervosa, in the long term. However, we could not identify differential effects of the two treatment regimes, which we had expected with regard to the very different therapeutic approaches. The similarities of outcome of both therapies predominate, with slightly better results in the case of the analytic in-patient treatment. The results are discussed with regard to the assumption that specific healing factors are involved in conflict-orientated treatments in addition to the "common factors' of psychotherapy.

Body image distortion in anorexia and bulimia nervosa: the role of perceived and actual control

It has been suggested that a desire for control is a central factor in eating disorders. There is, however, little evidence to support this clinical hypothesis. This experimental study examines the effects of actual and perceived control on a symptom of anorexia and bulimia nervosa-body image distortion. Using a learned helplessness paradigm, it was shown that eating-disordered and comparison women respond differently to manipulations of control. Anorexic and bulimic women appear to have a cognitive style of "mistaken pessimism," overestimating body size more when an easy task is perceived as difficult. In contrast, the comparison women are "mistaken optimists" overestimating less when they see a difficult task as being easy. The clinical implications are discussed and further research is proposed to extend these preliminary findings.

Perfectionism traits and perfectionistic self-presentation in eating disorder attitudes, characteristics, and symptoms

OBJECTIVE

The purpose of this study was to assess the association between several dimensions of perfectionism and measures of eating disorder symptoms, body image, and appearance self-esteem in college students.

METHOD

A sample of 81 female university students completed the Multidimensional Perfectionism Scale, the Perfectionistic Self-Presentation Scale, the Eating Attitudes Test, the Bulimia Test, the Body Image Avoidance Questionnaire, and two measures of self-esteem.

RESULTS

It was found that whereas self-oriented perfectionism was related only to anorexic symptoms, the social facets of perfectionism, especially socially prescribed perfectionism and the perfectionistic self-presentation dimensions, were related to eating disorder symptoms as well as body image avoidance and self-esteem.

DISCUSSION

The findings support the usefulness of differentiating personal and interpersonal dimensions of perfectionism as well as trait versus self-presentational aspects of perfectionism in investigating personality and attitudes and behaviors related to eating disorders.

Psychological factors in the etiology of binge eating

Numerous psychological factors have been hypothesized to play a role in the etiology of binge eating. This chapter proposes that female gender-role socialization puts girls at risk for the development of binge eating. Moreover, it is proposed that an understanding of risk requires an exploration of the developmental tasks of female adolescence. As research of the etiology of binge eating in particular and eating disorders in general begins to move away from testing single-factor causal models and toward testing complex, multifactorial models of causation, research needs to examine the psychological factors discussed in this chapter.

Processing of threat-related information by women with bulimic eating attitudes

It has been proposed that bulimic attitudes and behaviors serve the function of reducing awareness, especially where a situation is regarded as threatening. However, there is little evidence to support this model. Considering a non-eating-disordered population, this study tested the prediction that a higher level of bulimic eating attitudes will be associated with a characteristic pattern of cognitive processing, where the individual is slower to respond to threatening information. In a computer-driven test of information processing, it was shown that women with more bulimic attitudes were slower to respond to threatening than neutral words, while there was no such effect for the women with less bulimic attitudes. This finding was specific to bulimic attitudes, rather than simply being related to unhealthy eating attitudes in general. These findings support the "escape from awareness" model of bulimic attitudes and behavior. Further research is needed, particularly to verify these findings in women with diagnosable bulimic disorders.

The correlates of binge eating in two nonpatient samples

Binge eating in two nonpatient samples was examined as a function of actual body weight (expressed as BMI), attempts to control eating, food/weight preoccupation, and neuroticism. All of these factors were univariately associated with binge eating, but multivariate analyses indicated that food/weight preoccupation was the most powerful predictor, accounting for much of the common variance shared by the various correlates. This replicates previous work and suggests that the dynamics of subclinical bingeing are substantially similar to that found in the full DSM-III-R syndrome of bulimia nervosa.

Eating disorders with and without substance use disorders: a comparative study of inpatients

We assessed the co-occurrence of DSM-III-R axis I and II disorders and self-reported psychologic distress in inpatients with eating disorders with and without substance use disorders (ED-SUD and ED groups, respectively) and in a matched comparison sample with substance use disorders but no eating disorder (SUD group). The three groups showed similar distributions of axis I disorders but differed in the distribution of axis II disorders. Cluster B personality disorders were diagnosed more frequently in SUD and ED-SUD groups than in the ED group. In contrast, cluster C personality disorders were diagnosed more frequently in the ED group than in SUD and ED-SUD groups. The SUD group reported greater psychologic distress than ED and ED-SUD groups. Possible implications of the observed group differences for psychologic models of why these disorders may be associated are considered.

Identification of "binge-prone" women: an experimentally and psychometrically validated cluster analysis in a college population

This study investigated the escape model of binge eating through a cluster analysis using standardized measures. A sample of 126 undergraduate women underwent a manipulation of their level of cognition and were asked to "taste-test" several flavors of ice cream. Questionnaire data from these women were entered into a cluster analysis. Two groups emerged: women in the "binge-prone" group were significantly more depressed, had lower self-esteem, had more chaotic and extreme eating patterns, and were more self-conscious than those in the control group. In validation work, binge-prone women were shown to report elevated levels of bulimic symptomatology and, when in the presence of a food they enjoyed, to respond to increases in level of cognition by eating more. These results were consistent with some, but not all, of the components of the escape model.

The Emotional Eating Scale: the development of a measure to assess coping with negative affect by eating

The development of the Emotional Eating Scale (EES) is described. The factor solution replicated the scale's construction, revealing Anger/Frustration, Anxiety, and Depression subscales. All three subscales correlated highly with measures of binge eating, providing evidence of construct validity. None of the EES subscales correlated significantly with general measures of psychopathology. With few exceptions, changes in EES subscales correlated with treatment-related changes in binge eating. In support of the measure's discriminant efficiency, when compared with obese binge eaters, subscale scores of a sample of anxiety-disordered patients were significantly lower. Lack of correlation between a measure of cognitive restraint and EES subscales suggests that emotional eating may precipitate binge episodes among the obese independent of the level of restraint.

Reported sexual abuse and eating psychopathology: a review of the evidence for a causal link

It has been claimed that there is no specific link between a reported history of sexual abuse and the eating disorders. In particular, studies and reviews investigating the relationship between reported sexual abuse and the eating disorders have concluded that the prevalence rate of abuse among eating-disordered women is similar to the rates found in other psychiatric groups and in the general population. However, it is argued in this review that such a conclusion is based on an inappropriate level of analysis of the phenomena of sexual abuse and diagnosable eating disorders. When these two relatively blunt constructs are considered in finer detail, there appears to be a complex link between the nature of sexual abuse and specific bulimic symptomatology. This relationship is discussed with particular reference to important mediating factors (including dissociation, self-denigration, borderline personality disorder, and disclosure experiences), the functions of the bulimic behaviors, and the particular cognitive schemata that the victims of abuse may develop. The clinical implications of this relationship are considered, and suggestions are made for further research.

Relation among self-defeating personality, troubled eating patterns, and dissociation

Significant small correlations were found between scores on a measure of self-defeating personality with scores on the Bulimia Test-Revised (r = .27) and also scores on the Dissociative Experiences Scale (r = .20) for a sample of 165 college women. The correlation between the Bulimia Test and the Dissociative Experiences Scale was .26. Although the research literature led us to expect stronger relationships on theoretical and empirical grounds, it appears these small relationships were more likely due to the fact that scoring higher on all these measures indicates greater psychopathology.

Frequent dieting among adolescents: psychosocial and health behavior correlates

OBJECTIVES

The present study examined correlates of frequent dieting in 33,393 adolescents. It was hypothesized that frequent dieting would be correlated with negative psychosocial and health behavior outcomes.

METHODS

A comprehensive, school-based health behavior survey was administered in 1987 to public school students in grades 7 through 12 in Minnesota. Students self-reported dieting behavior; substance use; suicidal, sexual, and delinquent behavior; family and peer concerns; sick days; and abuse history. Differences on psychosocial and health behavior risk factors by dieting frequency and by purging status were assessed with multivariate logistic regression, with body mass index and demographic variables controlled.

RESULTS

Dieting frequency was associated with history of binge eating (females: odds ratio [OR] = 1.46, males: OR = 1.53); poor body image (females: OR = 0.56, males: OR = 0.63); lower connectedness to others (females: OR = 0.79); greater alcohol use (females: OR = 1.17); and greater tobacco use (females: OR = 1.08). Purging status was independently associated with negative risk factors in both males and females.

CONCLUSIONS

These findings suggest that frequent dieting efforts in adolescents should not be viewed in isolation, but rather in the broader context of health and risk-taking behaviors.

Alexithymia, obesity, and binge eating disorder

Eighty-three obese subjects with binge eating disorder (BED) were compared with 99 obese subjects not meeting criteria for BED on the Toronto Alexithymia Scale (TAS). Overall, the subjects in our sample were not significantly alexithymic, the mean global TAS score being 62.8 (SD = 10.2) which is comparable with the values found in non-patient control samples. Furthermore, the mean TAS scores did not differ between obese subjects with and without BED. However, we found a slightly higher prevalence of alexithymia (TAS total score 74 and above) in BED subjects compared with non-BED subjects (24.1% and 11.1%, respectively). A series of stepwise multiple regression analyses were run, exhibiting a significant relationship between the TAS and educational level and the Eating Disorder Inventory (EDI) subscales Interpersonal Distrust and Ineffectiveness. Age, body mass index, measures of depression, and eating pathology did not predict TAS scores.

Dissociation in bulimic and non-eating-disordered women

A relationship between dissociative experiences and the eating disorders has been reported. However the nature of that link is not clearly understood. This study investigates the links between dissociation (as measured by the Dissociative Experiences Scale-DES II) and eating psychopathology in a clinical group of bulimic women and a nonclinical group of undergraduates. In the nonclinical group, specific dissociative styles were found to be linked with bulimic attitudes on the Eating Attitudes Test. In the eating-disordered group, there was an association between the scales of the DES II and frequency of bringing. This association was primarily due to the effects of the dissociative style of absorption (e.g., daydreaming). Suggestions are made for further research, and the clinical implications of the findings are discussed.

Psychosocial theory and the creation of the risky self

This paper examines the transformation of individual identity in twentieth century psychological theory from the passive through to the interactive to the intra-active using models of behaviour, learning, beliefs, stress and pain. This shift in identity and the corresponding realignment of individual and environment is discussed in terms of changing locations of risks to health and the construction of the contemporary risky self.

Social interaction effects on restrained eating

The eating behavior of college women scoring within either the above-average or middle ranges on the Restraint Scale was compared following brief social encounters with male students or other female students, or a no-encounter control situation. The eating of average restraint women was significantly depressed following interaction with a partner whom the subjects considered attractive. For high restraint women a nonsignificant tendency towards disinhibition of eating following interaction with an attractive other occurred. Personality ratings by partners indicated that high restraint women presented a distinct social persona to male, but not female, strangers in the brief experimental interaction.

The assessment of obesity: theoretical background and practical advice

Developments in understanding the causes and consequences of obesity have important implications for the assessment of weight problems. Simple measurement of body weight is no longer sufficient. The evaluation should include measures of body composition, dietary quality, energy expenditure, risk factor status and body image. In this paper, the arguments in favour of a broader-based evaluation of obesity are presented and a range of assessment methods are discussed.

Sexual orientation as a factor in risk for binge eating and bulimia nervosa: a review

Research on binge eating and bulimia nervosa among lesbians and gay men is reviewed. The thesis that the different value pot on physical appearance in these groups may function as a mediator of risk for eating problems is considered. Studies indicate that gay men focus on their appearance more than heterosexual men and may be at higher risk. Lesbians, who are arguably less invested in societal norms of attractiveness, may be at lower risk than heterosexual women, but the findings are mixed. Implications for conceptual models of risk for bulimia nervosa, and for awareness of lesbian and gay experiences by therapists, are discussed.