Revisiting the affect regulation model of binge eating: a meta-analysis of studies using ecological momentary assessment

Initial test of an emotional avoidance model of restriction in anorexia nervosa using ecological momentary assessment

It has been hypothesized that restrictive eating allows individuals with anorexia nervosa (AN) to avoid contact with negative emotions; however, this presumption has not been directly tested. In this study, we conducted an initial investigation examining whether restrictive eating serves an emotional avoidance function among individuals with AN. Females with AN (n = 118) reported on negative and positive affect, anxiety/tension, and eating behaviors at multiple time points daily over a 2-week period using ecological momentary assessment methodology. Affective patterns were compared using generalized estimating equation models between days in which participants reported either: (1) relatively high restriction (without binge eating); (2) relatively low restriction (without binge eating); (3) binge eating; or (4) no restriction or binge eating. We hypothesized that, if restriction were functioning to avoid negative affect, average negative affect and anxiety/tension, as well as average negative and positive affect lability, would be lower and average positive affect would be higher on days characterized by high levels of restriction compared to other eating patterns. Contrary to hypotheses: (1) average negative affect, anxiety/tension, and positive affect were not significantly different between days characterized by high restriction and those characterized by low or no restriction; (2) Negative affect and anxiety/tension lability were higher on days characterized by high restriction compared to no restriction or binge eating days; (3) Anxiety/tension lability was higher on days characterized by high versus low levels of restriction. This patterns of findings does not support an avoidance model of restrictive eating for individuals with AN.

Negative affect, interpersonal perception, and binge eating behavior: An experience sampling study

OBJECTIVE

Etiological and maintenance models for disordered eating highlight the salience of negative affect and interpersonal dysfunction. This study employed a 14-day experience sampling procedure to assess the impact of negative affect and interpersonal perceptions on binge eating behavior.

METHOD

Young adult women (N = 40) with recurrent binge eating and significant clinical impairment recorded their mood, interpersonal behavior, and eating behaviors at six stratified semirandom intervals daily through the use of personal digital assistants.

RESULTS

Although momentary negative affect was associated with binge eating behavior, average levels of negative affect over the experience sampling period were not, and interpersonal problems moderated the relationship between negative affect and binge eating. Interpersonal problems also intensified the association between momentary interpersonal perceptions and binge eating behavior. Lagged analyses indicated that previous levels of negative affect and interpersonal style also influence binge eating.

DISCUSSION

The study findings suggest there may be important differences in how dispositional versus momentary experiences of negative affect are associated with binge eating. Results also highlight the importance of interpersonal problems for understanding relationships among negative affect, interpersonal perception, and binge eating behavior. These results offer several possibilities for attending to affective and interpersonal functioning in clinical practice.

The developmental effects of media-ideal internalization and self-objectification processes on adolescents' negative body-feelings, dietary restraint, and binge eating

Despite accumulated experimental evidence of the negative effects of exposure to media-idealized images, the degree to which body image, and eating related disturbances are caused by media portrayals of gendered beauty ideals remains controversial. On the basis of the most up-to-date meta-analysis of experimental studies indicating that media-idealized images have the most harmful and substantial impact on vulnerable individuals regardless of gender (i.e., "internalizers" and "self-objectifiers"), the current longitudinal study examined the direct and mediated links posited in objectification theory among media-ideal internalization, self-objectification, shame and anxiety surrounding the body and appearance, dietary restraint, and binge eating. Data collected from 685 adolescents aged between 14 and 15 at baseline (47 % males), who were interviewed and completed standardized measures annually over a 3-year period, were analyzed using a structural equation modeling approach. Results indicated that media-ideal internalization predicted later thinking and scrutinizing of one's body from an external observer's standpoint (or self-objectification), which then predicted later negative emotional experiences related to one's body and appearance. In turn, these negative emotional experiences predicted subsequent dietary restraint and binge eating, and each of these core features of eating disorders influenced each other. Differences in the strength of these associations across gender were not observed, and all indirect effects were significant. The study provides valuable information about how the cultural values embodied by gendered beauty ideals negatively influence adolescents' feelings, thoughts and behaviors regarding their own body, and on the complex processes involved in disordered eating. Practical implications are discussed.

Desire thinking: A risk factor for binge eating?

In the current study we explored the role of desire thinking in predicting binge eating independently of Body Mass Index, negative affect and irrational food beliefs. A sample of binge eaters (n=77) and a sample of non-binge eaters (n=185) completed the following self-report instruments: Hospital Anxiety and Depression Scale, Irrational Food Beliefs Scale, Desire Thinking Questionnaire, and Binge Eating Scale. Mann-Whitney U tests revealed that all variable scores were significantly higher for binge eaters than non-binge eaters. A logistic regression analysis indicated that verbal perseveration was a predictor of classification as a binge eater over and above Body Mass Index, negative affect and irrational food beliefs. A hierarchical regression analysis, on the combined sample, indicated that verbal perseveration predicted levels of binge eating independently of Body Mass Index, negative affect and irrational food beliefs. These results highlight the possible role of desire thinking as a risk factor for binge eating.

Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report

Transsexual (TS) individuals seem to display an increased risk in having eating disorders. Several case reports describe TS individuals with anorexia nervosa (AN). In order to understand better the impact of gender dysphoria (GD) and hormonal/surgical treatments on the occurrence and course of eating disorders in TS patients long term follow-up studies are needed. We present here a 41-year-old female-to-male TS patient suffering from AN. History revealed that pathological eating habits could strongly be associated with her GD. Hormonal and surgical treatments resulted in substantial improvement in the given eating disorder. The impact of GD on the development and treatment of eating disorder is discussed in this report.

Weight suppression in bulimia nervosa: Associations with biology and behavior

Bulimia nervosa (BN) is a serious eating disorder that can persist for years and contribute to medical complications and increased mortality, underscoring the need to better understand factors maintaining this disorder. Higher levels of weight suppression (WS) have been found to predict both the onset and maintenance of BN; however, no studies have examined mechanisms that may account for the effects of WS on BN. We hypothesized that high WS would lead to reduced leptin levels, which may increase risk of binge eating by modulating reward responses to food. The current study examined the relationship between WS, leptin levels, and the reinforcing value of food in women with BN (n = 32) and noneating disorder controls (n = 30). Participants provided information on WS, completed a fasting blood draw to obtain serum leptin, and completed a progressive ratio task to measure the reinforcing value of food. Individuals with BN had greater WS (p < .01) and reinforcing food value (p < .05) compared with controls. Additionally, higher WS was associated with both lower leptin (p < .05) and increased reinforcing value of food (p < .05). Contrary to hypotheses, BN and control participants did not differ on leptin levels, and leptin levels were not significantly associated with the reinforcing value of food. Findings support that efforts to conform to the thin ideal may alter drive to consume rewarding foods and leave women vulnerable to binge episodes. However, mechanisms through which WS contributes to food reward and binge eating remain unknown.

In search of a human self-regulation system

The capacity for self-regulation allows people to control their thoughts, behaviors, emotions, and desires. In spite of this impressive ability, failures of self-regulation are common and contribute to numerous societal problems, from obesity to drug addiction. Such failures frequently occur following exposure to highly tempting cues, during negative moods, or after self-regulatory resources have been depleted. Here we review the available neuroscientific evidence regarding self-regulation and its failures. At its core, self-regulation involves a critical balance between the strength of an impulse and an individual's ability to inhibit the desired behavior. Although neuroimaging and patient studies provide consistent evidence regarding the reward aspects of impulses and desires, the neural mechanisms that underlie the capacity for control have eluded consensus, with various executive control regions implicated in different studies. We outline the necessary properties for a self-regulation control system and suggest that the use of resting-state functional connectivity analyses may be useful for understanding how people regulate their behavior and why they sometimes fail in their attempts.

A risk and maintenance model for bulimia nervosa: From impulsive action to compulsive behavior

This article offers a new model for bulimia nervosa (BN) that explains both the initial impulsive nature of binge eating and purging, as well as the compulsive quality of the fully developed disorder. The model is based on a review of advances in research on BN and advances in relevant basic psychological science. It integrates transdiagnostic personality risk, eating-disorder-specific risk, reinforcement theory, cognitive neuroscience, and theory drawn from the drug addiction literature. We identify both a state-based and a trait-based risk pathway, and we then propose possible state-by-trait interaction risk processes. The state-based pathway emphasizes depletion of self-control. The trait-based pathway emphasizes transactions between the trait of negative urgency (the tendency to act rashly when distressed) and high-risk psychosocial learning. We then describe a process by which initially impulsive BN behaviors become compulsive over time, and we consider the clinical implications of our model. (PsycINFO Database Record

Could training executive function improve treatment outcomes for eating disorders?

Current gold standard treatments for eating disorders (EDs) lack satisfactory efficacy, and traditional psychological treatments do not directly address executive functioning deficits underpinning ED pathology. The goal of this paper is to explore the potential for enhancing ED treatment outcomes by improving executive functioning deficits that have been demonstrated to underlie eating pathology. To achieve our objective, we (1) review existing evidence for executive functioning deficits that underpin EDs and consider the extent to which these deficits could be targeted in neurocognitive training programs, (2) present the evidence for the one ED neurocognitive training program well-studied to date (Cognitive Remediation Therapy), (3) discuss the utility of neurocognitive training programs that have been developed for other psychiatric disorders with similar deficits, and (4) provide suggestions for the future development and research of neurocognitive training programs for EDs. Despite the fact that the body of empirical work on neurocognitive training programs for eating disorders is very small, we conclude that their potential is high given the combined evidence for the role of deficits in executive functioning in EDs, the initial promise of Cognitive Remediation Training, and the success in treating related conditions with neurocognitive training. Based on the evidence to date, it appears that the development and empirical evaluation of neurocognitive training programs for EDs is warranted.

Dimensions of emotion dysregulation in anorexia nervosa and bulimia nervosa: A conceptual review of the empirical literature

Several existing conceptual models and psychological interventions address or emphasize the role of emotion dysregulation in eating disorders. The current article uses Gratz and Roemer's (2004) multidimensional model of emotion regulation and dysregulation as a clinically relevant framework to review the extant literature on emotion dysregulation in anorexia nervosa (AN) and bulimia nervosa (BN). Specifically, the dimensions reviewed include: (1) the flexible use of adaptive and situationally appropriate strategies to modulate the duration and/or intensity of emotional responses, (2) the ability to successfully inhibit impulsive behavior and maintain goal-directed behavior in the context of emotional distress, (3) awareness, clarity, and acceptance of emotional states, and (4) the willingness to experience emotional distress in the pursuit of meaningful activities. The current review suggests that both AN and BN are characterized by broad emotion regulation deficits, with difficulties in emotion regulation across the four dimensions found to characterize both AN and BN, although a small number of more specific difficulties may distinguish the two disorders. The review concludes with a discussion of the clinical implications of the findings, as well as a summary of limitations of the existing empirical literature and suggestions for future research.

Boredom proneness and emotion regulation predict emotional eating

Emotional eating is considered a risk factor for eating disorders and an important contributor to obesity and its associated health problems. It has been suggested that boredom may be an important contributor to overeating, but has received relatively little attention. A sample of 552 college students was surveyed. Linear regression analyses found that proneness to boredom and difficulties in emotion regulation simultaneously predicted inappropriate eating behavior, including eating in response to boredom, other negative emotions, and external cues. The unique contributions of these variables to emotional eating were discussed. These findings help to further identify which individuals could be at risk for emotional eating and potentially for unhealthy weight gain.

Explicit and inferred motives for nonsuicidal self-injurious acts and urges in borderline and avoidant personality disorders

Nonsuicidal self-injury (NSSI) is a perplexing phenomenon that may have differing motives. The present study used experience sampling methods (ESM) which inquired explicitly about the motives for NSSI, but also enabled a temporal examination of the antecedents/consequences of NSSI; these allow us to infer other motives which were not explicitly endorsed. Adults (n = 152, aged 18-65) with borderline personality disorder (BPD), avoidant personality disorder (APD), or no psychopathology participated in a 3-week computerized diary study. We examined 5 classes of explicit motives for engaging in NSSI, finding support primarily for internally directed rather than interpersonally directed ones. We then used multilevel regression to examine changes in affect, cognition, and behavior surrounding moments of NSSI acts/urges compared with control moments (i.e., without NSSI). We examined changes in 5 scales of inferred motives, designed to correspond to the 5 classes of explicit motives. The results highlight differing motives for NSSI among individuals with BPD and APD, with some similarities (mostly in the explicit motives) and some differences (mostly in the inferred motives) between the disorders. Despite their infrequent explicit endorsement, fluctuations in interpersonally oriented scales were found surrounding NSSI acts/urges. This highlights the need to continue attending to interpersonal aspects of NSSI in research and in clinical practice. Additionally, NSSI urges, like acts, were followed by decline in affective/interpersonal distress (although in a delayed manner). Thus, interventions that build distress tolerance and enhance awareness for affective changes, and for antecedent/consequence patterns in NSSI, could help individuals resist the urge to self-injure.

Parental instrumental feeding, negative affect, and binge eating among overweight individuals

Parental instrumental feeding (i.e., rewarding children with food for perceived correct behaviors and punishing by taking away food for perceived incorrect behaviors) and negative affect are independently associated with binge eating in adulthood. However, less is known about interactions between these variables and binge eating. This study examined the relationship of retrospective reports of parental feeding practices and negative affect to binge eating. Participants were 165 overweight and obese undergraduate students at a large Mid-Atlantic University. High parental instrumental feeding strengthened the relationship between negative affect and binge eating. Also, individuals who reported low parental feeding practices reported similar binge eating regardless of negative affect. These findings suggest that overweight and obese individuals whose parents used more instrumental feeding practices are most likely to engage in binge eating in response to negative affect.

Eaten up by boredom: consuming food to escape awareness of the bored self

Research indicates that being bored affectively marks an appraised lack of meaning in the present situation and in life. We propose that state boredom increases eating in an attempt to distract from this experience, especially among people high in objective self-awareness. Three studies were conducted to investigate boredom’s effects on eating, both naturally occurring in a diary study and manipulated in two experiments. In Study 1, a week-long diary study showed that state boredom positively predicted calorie, fat, carbohydrate, and protein consumption. In Study 2, a high (vs. low) boredom task increased the desire to snack as opposed to eating something healthy, especially amongst those participants high in objective self-awareness. In addition, Study 3 demonstrated that among people high in objective self-awareness, high (vs. low) boredom increased the consumption of less healthy foods and the consumption of more exciting, healthy foods. However, this did not extend to unexciting, healthy food. Collectively, these novel findings signify the role of boredom in predicting maladaptive and adaptive eating behaviors as a function of the need to distant from the experience of boredom. Further, our results suggest that more exciting, healthy food serves as alternative to maladaptive consumption following boredom.

Behavioral, emotional, and situational context of purging episodes in anorexia nervosa

OBJECTIVE

The current study examined behavioral, emotional, and situational factors involved in purging among women with anorexia nervosa (AN).

METHOD

Women with AN (n=118) completed a two-week ecological momentary assessment protocol involving daily reports of eating disorder behaviors, mood, and stressful events. Generalized estimating equations examined the likelihood and context of purging following eating episodes involving both overeating and loss of control (binge eating; BE); loss of control only (LOC); overeating only (OE); and neither loss of control nor overeating (non-pathological eating; NE).

RESULTS

Relative to NE, purging was more likely to occur following BE, LOC, and OE (Wald chi-square = 18.05; p < .001). BE was more strongly associated with subsequent purging than LOC but not OE; the latter two did not differ from one another. Negative affect predicted purging following NE (Wald chi-square = 7.71; p = .005).

DISCUSSION

Binge eating involving large amounts of food was the strongest predictor of purging in AN, which challenges the notion that loss of control is the most salient aspect of experiencing distress in bulimia nervosa and BE disorder. Parallel to findings from the BE literature, negative affect strongly predicted purging following NE. Further research should clarify the function and triggers of purging in AN.

Binge eating in bariatric surgery candidates: The role of insecure attachment and emotion regulation

Binge eating has a high prevalence among bariatric patients and is associated with post-surgical weight gain. This study examined the potential mediating role of emotion regulation difficulties in the relation between attachment insecurity and binge eating among this population. Participants were 1388 adult pre-bariatric surgery candidates from an accredited bariatric surgery assessment centre in Toronto, Ontario. Participants completed measures of psychological functioning, including attachment style and emotion regulation. Mediation analyses revealed that difficulties with emotion regulation mediated a positive association between insecure-anxious attachment and binge eating. An insecure-avoidant attachment was found to have a non-significant association with binge eating when examining the total effect. However, when difficulties with emotion regulation were controlled for in the model to examine its role as a mediator, this association became significant, and emotion regulation difficulties also mediated the relationship between attachment avoidance and binge eating. These findings suggest that difficulties in emotion regulation may be an important clinical issue to address in order to reduce binge eating in adult bariatric surgery candidates.

Affect regulation and purging: An ecological momentary assessment study in purging disorder

Research suggests that affect may play an important role in the propensity to purge among women with purging disorder (PD). However, prior work has been constrained to cross-sectional or laboratory designs, which impact temporal interpretations and ecological validity. This study examined negative affect (NA) and positive affect (PA) in triggering and maintaining purging in PD using ecological momentary assessment. Women with PD (N = 24) made multiple daily ratings of affect and behavior for 2 weeks. Multilevel models examined associations between affect and purging at different levels of analysis, including a novel analytic approach to address the specificity of changes in affect relative to purging behavior by comparing trajectories of change on purge versus nonpurge days. For trajectories of affect over time, NA increased before purging and decreased following purging on purge days; however, only the decrease in NA following purging was significantly different from the trajectory of NA on nonpurge days. Conversely, PA failed to increase before purging on purge days compared with a matched time-point on nonpurge days. These findings suggest unique roles of PA in triggering and NA in maintaining purging in PD and support models in which purging functions to regulate affect. For comparisons of ratings before and after purging, NA increased and PA decreased after purging, highlighting how different analytic strategies produce different findings requiring integration into affect regulation models. These data provide insight into why women with PD purge after consuming normal amounts of food, a crucial first step for developing effective interventions.

Mediators involved in the relation between depressive symptoms and weight status in female adolescents and young adults

Depression may be a risk factor for overweight status, but mechanisms involved in this relationship are unclear. This study explored behavioral factors involved in the relationship between adolescent depression symptoms and adult overweight status. A population-based cohort of female participants in Project EAT (n=1,035) was followed over 10 years and reported on psychological functioning, weight status, and eating and activity patterns in early/middle adolescence (1999=Time 1; T1), middle adolescence/early young adulthood (2004=Time 2; T2), and early/middle young adulthood (2009=Time 3; T3). Structural equation models were fit which included T1 depression scores predicting overweight status at T3, with T2 fruit and vegetable consumption, moderate-to-vigorous physical activity, and binge eating examined as mediators. There were small but significant effects of T1 depression scores predicting an increased likelihood of T3 overweight status (standardized estimate=0.038; p=.007), and of T2 binge eating mediating the relation between T1 depression and T3 overweight status (standardized indirect effect estimate=.036; p=.009). Binge eating may be one pathway to overweight among depressed females, suggesting that recognition and treatment of eating pathology in individuals with depression may help prevent overweight. Examination of other behavioral (and non-behavioral) factors explaining the relationship between depression and overweight is warranted.

Minority stress and binge eating among lesbian and bisexual women

Previous research demonstrates that lesbian and bisexual (LB) women report more binge eating behaviors compared to heterosexual women although the explanations for this disparity are not well understood. LB women also experience distal (e.g., discrimination) and proximal (e.g., expectations of rejection) minority stressors that are related to negative mental and physical health outcomes. The present study investigated the association between minority stressors and binge eating behaviors in LB women. A sample of 164 LB women completed an online survey that included measures of distal and proximal sexual minority stressors, emotional-focused coping, social isolation, negative affect, and binge eating. The resultant model partially supported both the psychological mediation framework and the affect regulation model. The principal finding was that among LB women, proximal stressors were associated with social isolation and emotion-focused coping, which in turn were associated with negative affect and ultimately binge eating. Overall, the study provides evidence that minority stress is associated with binge eating and may partially explain the disparity in binge eating between LB and heterosexual women.

Emotion dysregulation, self-image and eating disorder symptoms in University Women

BACKGROUND

We studied associations between emotion dysregulation, self-image and eating disorder (ED) symptoms in university women, and contrasted two indirect effect models to examine possible intervening mechanisms to produce ED symptoms.

METHODS

252 female Swedish university students completed the Difficulties in Emotion Regulation Scale (DERS), the Structural Analysis of Social Behavior (SASB) self-image measure, and the Eating Disorder Examination Questionnaire (EDE-Q). Correlations between scales were followed by five simple mediation analysis pairs with two possible pathways using five ED symptom variables as outcome. The models posited either self-image or emotion dysregulation as mediator or independent variable, respectively. ED symptoms were EDE-Q Global score, objective binge eating episodes (OBE), subjective binge eating episodes (SBE), and two variants of EDE-Q excessive exercise.

RESULTS

Emotion dysregulation and self-image were strongly correlated, and both correlated moderately with EDE-Q Global score. There were distinct indirect effects through self-image on the relationship between emotion dysregulation and ED symptoms, but not vice versa. These indirect effects were evident in relation to cognitive ED symptoms and both OBE and SBE, but not in relation to excessive exercise.

CONCLUSIONS

Results suggest that even if closely related, emotion dysregulation and self-image both contribute unique knowledge in relation to ED symptoms. Self-image as an intervening mechanism between emotion dysregulation and ED symptoms is relevant for models of the development, maintenance and treatment of ED, as well as treatment focus.

Emotion regulation model in binge eating disorder and obesity--a systematic review

Deficits in emotion regulation processes are a common and widely used explanation for the development and maintenance of binge eating disorder (BED). It is assumed that BED patients - as they have difficulty regulating their negative emotions - use binge eating to cope with these emotions and to find relief. However, the number of experimental studies investigating this assumption is scarce and the differentiation of obese individuals with and without BED regarding the emotion regulation model is not verified. We reviewed literature for experimental studies investigating the emotion regulation model in obese patients (OB) with and without BED. Our search resulted in 18 experimental studies examining the triggering effect of negative emotions for binge eating or its effects on subsequent relief. We found evidence indicating that negative emotion serves as a trigger for binge eating in the BED group unlike the obese group without BED. Considering the small number of studies, we found evidence for a (short-term) improvement of mood through food intake, irrespective of group.

The Role of Ambulatory Assessment in Psychological Science

We describe the current use and future promise of an innovative methodology, ambulatory assessment (AA), that can be used to investigate psychological, emotional, behavioral, and biological processes of individuals in their daily life. The term AA encompasses a wide range of methods used to study people in their natural environment, including momentary self-report, observational, and physiological. We emphasize applications of AA that integrate two or more of these methods, discuss the smart phone as a hub or access point for AA, and discuss future applications of AA methodology to the science of psychology. We pay particular attention to the development and application of Wireless Body Area Networks (WBANs) that can be implemented with smart phones and wireless physiological monitoring devices, and we close by discussing future applications of this approach to matters relevant to psychological science.

Are Extremes of Consumption in Eating Disorders Related to an Altered Balance between Reward and Inhibition?

The primary defining characteristic of a diagnosis of an eating disorder (ED) is the "disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food" (DSM V; American Psychiatric Association, 2013). There is a spectrum, ranging from those who severely restrict eating and become emaciated on one end to those who binge and overconsume, usually accompanied by some form of compensatory behaviors, on the other. How can we understand reasons for such extremes of food consummatory behaviors? Recent work on obesity and substance use disorders has identified behaviors and neural pathways that play a powerful role in human consummatory behaviors. That is, corticostriatal limbic and dorsal cognitive neural circuitry can make drugs and food rewarding, but also engage self-control mechanisms that may inhibit their use. Importantly, there is considerable evidence that alterations of these systems also occur in ED. This paper explores the hypothesis that an altered balance of reward and inhibition contributes to altered extremes of response to salient stimuli, such as food. We will review recent studies that show altered sensitivity to reward and punishment in ED, with evidence of altered activity in corticostriatal and insula processes with respect to monetary gains or losses, and tastes of palatable foods. We will also discuss evidence for a spectrum of extremes of inhibition and dysregulation behaviors in ED supported by studies suggesting that this is related to top-down self-control mechanisms. The lack of a mechanistic understanding of ED has thwarted efforts for evidence-based approaches to develop interventions. Understanding how ED behavior is encoded in neural circuits would provide a foundation for developing more specific and effective treatment approaches.

Do emotional eating urges regulate affect? Concurrent and prospective associations and implications for risk models of binge eating

OBJECTIVE

Emotional eating (EE) reflects an urge to eat in response to emotional rather than physical cues and is a risk factor for the development of binge eating. EE has been conceptualized as an attempt to regulate negative affect (NA), a posited maintenance factor for binge eating. However, no study has examined whether EE urges regulate affect. Further, no studies have examined longitudinal associations between EE urges and positive affect (PA).

METHOD

We examined within-subject longitudinal associations between affect and EE urges in a community-based sample of female twins (mean age = 17.8 years). Participants (N = 239) completed ratings of affect and EE urges for 45 consecutive days.

RESULTS

Greater NA was concurrently associated with greater EE urges. Additionally, greater EE urges predicted worse NA for both concurrent and prospective (next-day) analyses. Finally, lower PA was associated with greater EE urges in concurrent analyses, but there were no prospective associations between changes in PA and EE urges.

DISCUSSION

EE urges do not appear to effectively regulate affect. EE urges in a community-based sample appear to have the same functional relationship with affect as binge eating in clinical samples, further supporting EE as a useful dimensional construct for examining processes related to binge eating.

Eating behaviors and negative affect in college women's everyday lives

OBJECTIVE

A growing body of research seeks to understand the relationship between mood and eating behaviors. Ecological Momentary Assessment (EMA) methods provide a method for assessing these processes in natural settings. We used EMA to examine the relationship between mood and eating behaviors in everyday life among women with subclinical disordered eating behaviors.

METHOD

Participants (N = 127, age M = 19.6 years, BMI M = 25.5) completed five daily EMA reports on palmtop computers for 1 week. Assessments included measures of negative affect (NA) and eating-related behavior during eating (eating large amounts of food, loss of control over eating, and restricting food intake) and noneating episodes (skip eating to control weight/shape). Time-lagged multilevel models tested mood-eating behavior relationships.

RESULTS

Higher NA did not precede any unhealthy eating and weight control behaviors. However, NA was higher when women reported eating large quantities of food, losing control over eating, and restricting food intake during their most recent eating episode, but not after skipping eating to control weight/shape.

DISCUSSION

These findings elucidate the processes in daily life that may influence the development and maintenance of unhealthy eating and weight control behaviors that, in turn, can inform interventions.

Loneliness mediates the relationship between emotion dysregulation and bulimia nervosa/binge eating disorder psychopathology in a clinical sample

Emotion dysregulation has been linked to binge eating disorder (BED) and bulimia nervosa (BN) although the mechanisms by which it affects BN/BED psychopathology are unclear. This study tested loneliness as a mediator between emotion dysregulation and BN/BED psychopathology. A treatment-seeking sample of 107 women with BN or BED was assessed for loneliness (UCLA Loneliness Scale), emotion dysregulation (Difficulties in Emotion Regulation Scale), and BN/BED psychopathology (Eating Disorder Examination) before treatment. Hierarchical linear regressions and bootstrapping mediation models were run. Greater overall emotion dysregulation was associated with greater BN/BED psychopathology, mediated by loneliness (95 % CI 0.03, 0.09). Emotion dysregulation, however, did not mediate between loneliness and BN/BED psychopathology (95 % CI −0.01, 0.01). Targeting loneliness may effectively treat emotional aspects of BN/BED in women.

Escaping from body image shame and harsh self-criticism: exploration of underlying mechanisms of binge eating

Shame has been highlighted as a key component of eating psychopathology. However, the specific impact of body image shame on binge eating and the mechanisms through which it operates remained unexplored. The current study tests a model examining the role that body image shame plays in binge eating and the mediator effect of self-criticism on this association, while controlling for the effect of depressive symptoms, in 329 women from the general population and college students. Correlation analyses showed that binge eating is positively associated with depressive symptoms, body image shame, and self-criticism, namely with a more severe form of self-criticism characterized by self-disgust, hating and wanting to hurt the self - hated self. Furthermore, results indicated that the path model explained 32% of binge eating behaviours and confirmed that body image shame has a significant direct effect on binge eating, and that this effect is partially mediated by increased hated self. These findings suggest that binge eating may emerge as a maladaptive way to cope with the threat of being negatively viewed by others because of one's physical appearance and the consequent engagement in a severe critical self-relating style marked by hatred, disgust and contempt towards the self. This study contributes therefore for the understanding of the processes underlying binge eating. Also, these findings have important research and clinical implications, supporting the relevance of developing eating disorder treatments that specifically target shame and self-criticism, through the development of self-compassionate skills.

Frontostriatal circuits and the development of bulimia nervosa

Bulimia nervosa (BN) is characterized by both recurrent episodes of binge eating that are, in part, defined by a sense of loss of control and compensatory behaviors to avoid weight gain. Impulsive behaviors are also common in individuals with BN, indicating more pervasive difficulties in behavioral self-regulation. Findings from functional and anatomical neuroimaging studies of individuals with BN suggest dysfunction in the dorsal frontostriatal circuits that support self-regulatory capacities and habit learning and in overlapping ventral circuits that support reward processing and reward-based learning. In this review, we describe the normal development of frontostriatal circuits and then present behavioral and neuroimaging data from adolescents and adults with BN. These data suggest that the abnormal maturation of frontostriatal circuits may contribute to the habitual binge-eating and purging behaviors of BN. Future longitudinal imaging studies will improve understanding of how these circuits contribute to the developmental trajectory of BN and will inform novel interventions that could target or prevent the impulsive and habit-like features of this disorder.

Using ecological momentary assessment to examine interpersonal and affective predictors of loss of control eating in adolescent girls

OBJECTIVE

Pediatric loss of control (LOC) eating is predictive of partial- and full-syndrome binge eating disorder. The interpersonal model proposes that LOC eating is used to cope with negative mood states resulting from interpersonal distress, possibly on a momentary level. We therefore examined temporal associations between interpersonal problems, negative affect, and LOC eating among overweight adolescent girls using ecological momentary assessment (EMA).

METHOD

Thirty overweight and obese (≥85th body mass index (BMI) percentile; BMI: M = 36.13, SD = 7.49 kg/m(2)) adolescent females (Age: M = 14.92, SD = 1.54 y; 60.0% African American) who reported at least two LOC episodes in the past month completed self-report momentary ratings of interpersonal problems, state affect, and LOC eating for 2 weeks. A series of 2-level multilevel models with centering within subjects was conducted.

RESULTS

Between- and within-subjects interpersonal problems (p's < .05), but not between- (p = .12) or within- (p = .32) subjects negative affect predicted momentary LOC eating. At the between-subjects level, interpersonal problems significantly predicted increases in negative affect (p < 001).

DISCUSSION

Naturalistic data lend support to the predictive value of interpersonal problems for LOC eating among adolescents. Interventions targeting interpersonal factors on a momentary basis may be useful during this developmental stage.

Optimizing prediction of binge eating episodes: a comparison approach to test alternative conceptualizations of the affect regulation model

BACKGROUND

Although a wealth of studies have tested the link between negative mood states and likelihood of a subsequent binge eating episode, the assumption that this relationship follows a typical linear dose-response pattern (i.e., that risk of a binge episode increases in proportion to level of negative mood) has not been challenged. The present study demonstrates the applicability of an alternative, non-linear conceptualization of this relationship, in which the strength of association between negative mood and probability of a binge episode increases above a threshold value for the mood variable relative to the slope below this threshold value (threshold dose response model).

METHODS

A sample of 93 women aged 18 to 40 completed an online survey at random intervals seven times per day for a period of one week. Participants self-reported their current mood state and whether they had recently engaged in an eating episode symptomatic of a binge.

RESULTS

As hypothesized, the threshold approach was a better predictor than the linear dose-response modeling of likelihood of a binge episode. The superiority of the threshold approach was found even at low levels of negative mood (3 out of 10, with higher scores reflecting more negative mood). Additionally, severity of negative mood beyond this threshold value appears to be useful for predicting time to onset of a binge episode.

CONCLUSIONS

Present findings suggest that simple dose-response formulations for the association between negative mood and onset of binge episodes miss vital aspects of this relationship. Most notably, the impact of mood on binge eating appears to depend on whether a threshold value of negative mood has been breached, and elevation in mood beyond this point may be useful for clinicians and researchers to identify time to onset.

A New Frontier: Integrating Behavioral and Digital Technology to Promote Health Behavior

Modifiable behavioral risk factors such as cigarette smoking, physical inactivity, and obesity contribute to over 40 % of premature deaths in the USA. Advances in digital and information technology are creating unprecedented opportunities for behavior analysts to assess and modify these risk factors. Technological advances include mobile devices, wearable sensors, biomarker detectors, and real-time access to therapeutic support via information technology. Integrating these advances with behavioral technology in the form of conceptually systematic principles and procedures could usher in a new generation of effective and scalable behavioral interventions targeting health behavior. In this selective review of the literature, we discuss how technological tools can assess and modify a range of antecedents and consequences of healthy and unhealthy behavior. We also describe practical, methodological, and conceptual advantages for behavior analysts that stem from the use of technology to assess and treat health behavior.

Dietary-induced binge eating increases prefrontal cortex neural activation to restraint stress and increases binge food consumption following chronic guanfacine

Binge eating is a prominent feature of bulimia nervosa and binge eating disorder. Stress or perceived stress is an often-cited reason for binge eating. One notion is that the neural pathways that overlap with stress reactivity and feeding behavior are altered by recurrent binge eating. Using young adult female rats in a dietary-induced binge eating model (30 min access to binge food with or without 24-h calorie restriction, twice a week, for 6 weeks) we measured the neural activation by c-Fos immunoreactivity to the binge food (vegetable shortening mixed with 10% sucrose) in bingeing and non-bingeing animals under acute stress (immobilization; 1 h) or no stress conditions. There was an increase in the number of immunopositive cells in the dorsal medial prefrontal cortex (mPFC) in stressed animals previously exposed to the binge eating feeding schedules. Because attention deficit hyperactive disorder (ADHD) medications target the mPFC and have some efficacy at reducing binge eating in clinical populations, we examined whether chronic (2 weeks; via IP osmotic mini-pumps) treatment with a selective alpha-2A adrenergic agonist (0.5 mg/kg/day), guanfacine, would reduce binge-like eating. In the binge group with only scheduled access to binge food (30 min; twice a week; 8 weeks), guanfacine increased total calories consumed during the 30-min access period from the 2-week pre-treatment baseline and increased binge food consumption compared with saline-treated animals. These experiments suggest that mPFC is differentially activated in response to an immobilization stress in animals under different dietary conditions and chronic guanfacine, at the dose tested, was ineffective at reducing binge-like eating.

Examining the role of distress tolerance and negative urgency in binge eating behavior among women

The current study examined whether distress tolerance and negative urgency moderate the link between depressive symptoms and binge eating frequency, and between disordered eating attitudes and binge eating frequency. Young adult women (N=186) completed questionnaires assessing depressive symptoms, cognitive restraint, eating, shape and weight concerns, distress tolerance, impulsivity (including negative urgency), and binge eating. After controlling for body mass index, race/ethnicity, and other domains of impulsivity, negative urgency was significantly associated with binge eating above and beyond the influence of disordered eating attitudes and depressive symptoms. Distress tolerance, in contrast, was not associated with binge eating. In addition, neither negative urgency nor distress tolerance moderated the associations between disordered eating attitudes and binge eating frequency, or between depressive symptoms and binge eating. Results support the additive role of difficulties responding adaptively to distress in binge eating frequency, above and beyond the influence of emotional distress. Findings highlight the potential value of focusing on negative urgency in targeted treatments for binge eating among women. Importantly, results from the current study differ from those of previous research; these discrepancies could be the result of variations in sample characteristics and approaches to the assessment of binge eating behavior. Additional research, including longitudinal studies and research using "real-time" assessment strategies, such as ecological momentary assessment, is necessary to elucidate further the role of various emotion regulation strategies in maintaining binge eating behavior in adult women.

Two pathways toward impulsive action: an integrative risk model for bulimic behavior in youth

BACKGROUND

This study provides an integrative review of existing risk factors and models for bulimia nervosa (BN) in young girls. We offer a new model for BN that describes two pathways of risk that may lead to the initial impulsive act of binge eating and purging in children and adolescents.

SCOPE

We conducted a selective literature review, focusing on existing and new risk processes for BN in this select population.

FINDINGS

We identify two ways in which girls increase their risk to begin engaging in the impulsive behavior of binge eating and purging. The first is state-based: the experience of negative mood, in girls attempting to restrain eating, leads to the depletion of self-control and thus increased risk for loss of control eating. The second is personality-based: elevations on the trait of negative urgency, or the tendency to act rashly when distressed, increase risk, particularly in conjunction with high-risk psychosocial learning. We then briefly discuss how these behaviors are reinforced, putting girls at further risk for developing BN.

CONCLUSIONS

We highlight several areas in which further inquiry is necessary, and we discuss the clinical implications of the new risk model we described.

Current Emotion Research in Health Behavior Science

In the past two to three decades health behavior scientists have increasingly emphasized affect-related concepts (including, but not limited to emotion) in their attempts to understand and facilitate change in important health behaviors, such as smoking, eating, physical activity, substance abuse, and sex. This article provides a narrative review of this burgeoning literature, including relevant theory and research on affective response (e.g., hedonic response to eating and drug use), incidental affect (e.g., work-related stress as a determinant of alcohol use), affect processing (e.g., anticipated regret for illicit sex or skipping an exercise session), and affectively charged motivation (e.g., cigarette craving). An integrative dual-processing framework is presented that suggests pathways through which affect-related concepts may interrelate to influence health behavior.

Latent profile analysis of eating episodes in anorexia nervosa

BACKGROUND

Despite being characterized primarily by disturbances in eating behavior, relatively little is known about specific eating behaviors in anorexia nervosa (AN) and how they relate to different emotional, behavioral, and environmental features.

METHODS

Women with AN (n = 118) completed a 2-week ecological momentary assessment (EMA) protocol during which they reported on daily eating- and mood-related patterns. Latent profile analysis was used to identify classes of eating episodes based on the presence or absence of the following indicators: loss of control; overeating; eating by oneself; food avoidance; and dietary restraint.

RESULTS

The best-fitting model supported a 5-class solution: avoidant eating; solitary eating; binge eating; restrictive eating; and loss of control eating. The loss of control and binge eating classes were characterized by high levels of concurrent negative affect and a greater likelihood of engaging in compensatory behaviors. The restrictive eating class was associated with the greatest number of concurrently-reported stressful events, while the avoidant and solitary eating episode classes were characterized by relatively few accompanying stressful events. Body checking was least likely to occur in conjunction with restrictive eating behaviors.

CONCLUSIONS

Results support the presence of discrete types of eating episodes in AN that are associated with varying degrees of negative affect, stress, and behavioral features of eating disorders. Loss of control and dietary restriction may serve distinct functional purposes in AN, as highlighted by their differing associations with negative affect and stress. Clinical interventions for AN may benefit from targeting functional aspects of eating behavior among those with the disorder.

The role of affect in the maintenance of anorexia nervosa: evidence from a naturalistic assessment of momentary behaviors and emotion

The current study examines the relationship of affect and eating disorder behavior in anorexia nervosa (AN) using ecological momentary assessment. Participants were 118 adult females recruited at three sites from eating disorder treatment centers and community advertisements. All participants met full Diagnostic and statistical manual of mental disorders (4th ed.) criteria or subthreshold criteria for AN. Participants were provided handheld computers and asked to report positive affect, negative affect, loss of control (LOC) eating, purging, exercise, drinking fluids to curb appetite, and weighing one's self multiple times per day as well as dietary restriction once daily over a 2-week interval. Mixed-effects models were used to examine the extent to which affective states predict dietary restriction. In addition, we used two analytic approaches to compare affect before and after other eating disorder behaviors. We found that higher daily ratings of negative affect were associated with a greater likelihood of dietary restriction on subsequent days. When examining the single rating immediately before and after behaviors, we found that negative affect increased significantly after LOC eating, purging, the combination of LOC and eating/purging, and weighing of one's self. Using this same analytic approach, we also found negative affect to decrease significantly after the consumption of fluids to curb appetite and exercise. When examining the covariation of AN behaviors and negative affect assessed multiple times in the hours and minutes before the behaviors, we found negative affect significantly increased before LOC eating, purging, the combination of LOC eating/and purging, and weighing behavior. Negative affect also significantly decreased after the occurrence of these behaviors. These findings are consistent with the idea that that negative affect is potentially a critical maintenance mechanism of some AN symptoms, but that the analytic approach used to examine affect and behavior may have significant implications on the interpretation of findings.

Tests of an extension of the dual pathway model of bulimic symptoms to the state-based level

The dual pathway model proposes that trait body dissatisfaction leads to bulimic symptoms via two distinct pathways: dieting and trait negative affect. As many of these modelled variables have state-based equivalents, the present study evaluated the generalisability of this model to predict associations between state body dissatisfaction and instances of disordered eating. 124 women aged 18 to 40 years completed an online survey (accessed via a mobile phone device with web access) over a 7-day period. The mobile phone device prompted participants at random intervals seven times daily to self-report their state body dissatisfaction, current mood experiences, dieting attempts, and disordered eating practices. Multi-level mediation modelling revealed that both negative mood states and dieting significantly mediated the state body dissatisfaction-disordered eating relationships, although the strength of these associations depended on the aspect of disordered eating measured and individual differences in trait body dissatisfaction, internalization of appearance standards, tendency towards dieting, and BMI. Collectively, these results not only support adapting the dual pathway model to the state-level, but also suggest that several of the model implied pathways may be more relevant for individuals with more pathological eating- and body-related concerns and behaviours.

The role of trait and ability emotional intelligence in bulimic symptoms

Bulimia is characterized by poor affect regulation, yet the role of emotional intelligence (EI) is little understood. This study examined associations between EI and bulimic symptoms using 235 women from community and student populations. They completed measures of trait and ability EI, and the Eating Disorders Diagnostic Scale. Results showed that deficiencies in different aspects of trait EI and/or ability EI are a function of symptom type: binge eating, compensatory behaviours or weight and shape concerns. Consistent with affect regulation models, self-regulatory aspects of trait EI were related to two bulimic symptoms: binge eating and weight and shape concerns. Ability-based self-emotion management was not important, and explanatory power of lower-level EI facets (traits or abilities) was not superior to more broadly defined EI factors. Results support the conclusion that trait and ability EI may maintain subclinical levels of bulimic symptoms but have different paths.

Individual differences in negative affect and weekly variability in binge eating frequency

OBJECTIVE

To examine the relationship of neuroticism and negative affect (NA) lability with weekly binge eating fluctuations between binge eating disorder (BED) and bulimia nervosa (BN).

METHOD

Individuals with BED (n = 30) and BN (n = 54) from the community completed self-report measures at baseline and prospectively for 12 consecutive weeks. Weekly data were analyzed by using (mean) squared successive deviation to account for fluctuations in NA and binge eating from week to week.

RESULTS

Generalized estimating equations revealed the presence of a two-way interaction between neuroticism and NA lability predicting binge eating fluctuations (Wald χ(2) = 8.25; df = 1; p = .004), indicating that higher NA lability was only related to larger fluctuations in the frequency of binge eating episodes when present in individuals who were also high on neuroticism. An interaction was also detected between eating disorder diagnosis and NA lability, but this was accounted for by differences in average NA between the diagnoses.

DISCUSSION

This study highlights the relevance of two traits and their interaction in understanding individual differences in binge eating fluctuations. Additionally, findings indicate that diagnostic differences in average NA may impact binge eating fluctuations and NA lability.

Surgency and negative affectivity, but not effortful control, are uniquely associated with obesogenic eating behaviors among low-income preschoolers

Despite increased attention to the role of temperament in children's obesogenic eating behaviors, there is a paucity of research examining whether different dimensions of temperament may be differentially associated with specific eating behaviors among preschool-age children. The purpose of the current study was to examine whether three temperament dimensions (surgency, negative affectivity, and effortful control) were uniquely associated with six obesogenic eating behaviors (caregiver-reported food responsiveness, enjoyment of food, emotional overeating, satiety responsiveness, and tantrums over food; and observed eating in the absence of hunger) among low-income preschool-age children, covarying home environment quality. Results showed that temperament dimensions were differentially associated with different eating behaviors. Specifically, preschoolers with higher surgency were more likely to overeat in response to external cues, have frequent desire to eat, derive pleasure from food, and eat in the absence of hunger. In contrast, preschoolers with higher negative affectivity were more likely to have tantrums over being denied food and less likely to eat in the absence of hunger. Effortful control was not uniquely associated with obesogenic eating behavior. Findings remained significant even when home chaos was accounted for, suggesting that child surgency and negative affectivity are important to consider, independent of home environment. Results are discussed with regard to theoretical implications for the study of childhood obesity and for applied prevention implications.

A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa

BACKGROUND

The purpose of this investigation was to compare a new psychotherapy for bulimia nervosa (BN), integrative cognitive-affective therapy (ICAT), with an established treatment, 'enhanced' cognitive-behavioral therapy (CBT-E).

METHOD

Eighty adults with symptoms of BN were randomized to ICAT or CBT-E for 21 sessions over 19 weeks. Bulimic symptoms, measured by the Eating Disorder Examination (EDE), were assessed at baseline, at the end of treatment (EOT) and at the 4-month follow-up. Treatment outcome, measured by binge eating frequency, purging frequency, global eating disorder severity, emotion regulation, self-oriented cognition, depression, anxiety and self-esteem, was determined using generalized estimating equations (GEEs), logistic regression and a general linear model (intent-to-treat).

RESULTS

Both treatments were associated with significant improvement in bulimic symptoms and in all measures of outcome, and no statistically significant differences were observed between the two conditions at EOT or follow-up. Intent-to-treat abstinence rates for ICAT (37.5% at EOT, 32.5% at follow-up) and CBT-E (22.5% at both EOT and follow-up) were not significantly different.

CONCLUSIONS

ICAT was associated with significant improvements in bulimic and associated symptoms that did not differ from those obtained with CBT-E. This initial randomized controlled trial of a new individual psychotherapy for BN suggests that targeting emotion and self-oriented cognition in the context of nutritional rehabilitation may be efficacious and worthy of further study.