Maintenance of binge eating through negative mood: a naturalistic comparison of binge eating disorder and bulimia nervosa

Dietary intake of adults with eating disorders: A systematic review and meta-analysis

Studies have confirmed the link between altered dietary intake and eating disorders (EDs), although no systematic assessment of this research exists. Rigorous synthesis of dietary intake in anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and similar EDs is needed to explore similarities and differences. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we conducted a systematic review and quantitative synthesis of studies of dietary intake. Searches of three electronic databases resulted in thirty-nine included studies. Meta-analyses of subsets of these studies were undertaken to summarise macronutrient intake across AN, BN, and BED. Study quality was assessed using the American Academy of Nutrition and Dietetics Quality Criteria Checklist, with ratings either Positive (k = 27) or Neutral (k = 12). Adults with AN had low energy intake and those with BED reported elevated macronutrient intake. Individuals with BN reported wide variation in energy intake, including some of the highest estimates. Individuals with AN were likely to under-consume key micronutrients, with sodium potentially over-consumed in BN and BED. Vitamin D was under-consumed across all disorders. This meta-analysis highlights important diagnostic differences and synthesises dietary intake in EDs, with particular relevance to risk assessment and treatment.

Are you how you eat? Aspects of self-awareness in eating disorders

Eating disorders (ED) are severe psychiatric disorders characterized by dysfunctional behaviors related to eating or weight control, with profound impacts on health, quality of life, and the financial burden of affected individuals and society at large. Given that these disorders involve disturbances in self-perception, it is crucial to comprehend the role of self-awareness in their prevalence and maintenance. This literature review presents different self-awareness processes, discussing their functioning across different levels of complexity. By deconstructing this concept, we can gain a better understanding of how each facet of self and personality relates to the symptoms of these disorders. Understanding the absence or impairment of self-awareness in ED holds significant implications for diagnosis, treatment, and overall management. By recognizing and comprehending the characteristics of self-awareness, clinicians can develop tailored interventions and evidence-based treatments for individuals with ED. Furthermore, this narrative review underscores the importance of considering temperament and personality factors in the context of ED, as temperament traits and personality characteristics may interact with self-awareness processes, influencing the development and maintenance of ED. Ultimately, the results highlight the pressing need for further research on the development of effective interventions and support strategies grounded in the aspects of self-awareness mechanisms for individuals affected by these disorders.

Divergent trajectories of positive affect following maladaptive and non-maladaptive exercise among individuals with binge-spectrum eating disorders

OBJECTIVE

Individuals with eating disorders (EDs) often engage in maladaptive exercise (e.g., feeling driven, or to "compensate" for eating) which maintains eating pathology. Maladaptive exercise has been theorized to help individuals with EDs regulate emotions by enhancing positive affect (PA) and reducing negative affect (NA) associated with binge episodes and poor body image. However, no research has considered the presence of non-maladaptive exercise or evaluated this theory in binge-spectrum EDs.

METHODS

This study evaluated affective trajectories pre- and post-exercise and examined exercise type (maladaptive or non-maladaptive) as a moderator. We recruited adults with binge-spectrum EDs (N = 107; n = 84 endorsed exercise) to complete a 7- to 14-day ecological momentary assessment protocol assessing NA (anxiety, guilt, and sadness), PA (excitement and cheerfulness), and exercise.

RESULTS

There was a significant quadratic trajectory of PA pre-exercise, suggesting that the upward trajectory of PA leveled out as it moved closer to an exercise episode. Exercise type significantly moderated the cubic trajectory of PA post-exercise, such that the upward trajectory of PA accelerated in the hours following non-maladaptive exercise episodes while the downward trajectory of PA accelerated in the hours following maladaptive exercise episodes. No trajectories of NA demonstrated significant effects.

CONCLUSIONS

Pre-exercise trajectories of PA may reflect positive expectancies around exercise. Post-exercise trajectories of PA suggest that non-maladaptive exercise promotes increased PA. Future research should evaluate when, and for whom, exercise serves to regulate affect and examine other momentary risk factors of exercise in EDs.

PUBLIC SIGNIFICANCE

Individuals with EDs often engage in maladaptive exercise (e.g., feeling driven, or to "compensate" for eating). Maladaptive exercise has been theorized to help individuals with EDs regulate emotions. This study evaluated affective trajectories pre- and post-exercise and examined whether exercise type (maladaptive or non-maladaptive) changed these trajectories. Pre-exercise trajectories of PA may reflect positive expectancies around exercise. Post-exercise trajectories of PA suggest that non-maladaptive exercise promotes increased PA.

Toward Individualized Prediction of Binge-Eating Episodes Based on Ecological Momentary Assessment Data: Item Development and Pilot Study in Patients With Bulimia Nervosa and Binge-Eating Disorder

BACKGROUND

Prevention of binge eating through just-in-time mobile interventions requires the prediction of respective high-risk times, for example, through preceding affective states or associated contexts. However, these factors and states are highly idiographic; thus, prediction models based on averages across individuals often fail.

OBJECTIVE

We developed an idiographic, within-individual binge-eating prediction approach based on ecological momentary assessment (EMA) data.

METHODS

We first derived a novel EMA-item set that covers a broad set of potential idiographic binge-eating antecedents from literature and an eating disorder focus group (n=11). The final EMA-item set (6 prompts per day for 14 days) was assessed in female patients with bulimia nervosa or binge-eating disorder. We used a correlation-based machine learning approach (Best Items Scale that is Cross-validated, Unit-weighted, Informative, and Transparent) to select parsimonious, idiographic item subsets and predict binge-eating occurrence from EMA data (32 items assessing antecedent contextual and affective states and 12 time-derived predictors).

RESULTS

On average 67.3 (SD 13.4; range 43-84) EMA observations were analyzed within participants (n=13). The derived item subsets predicted binge-eating episodes with high accuracy on average (mean area under the curve 0.80, SD 0.15; mean 95% CI 0.63-0.95; mean specificity 0.87, SD 0.08; mean sensitivity 0.79, SD 0.19; mean maximum reliability of r_D 0.40, SD 0.13; and mean r_CV 0.13, SD 0.31). Across patients, highly heterogeneous predictor sets of varying sizes (mean 7.31, SD 1.49; range 5-9 predictors) were chosen for the respective best prediction models.

CONCLUSIONS

Predicting binge-eating episodes from psychological and contextual states seems feasible and accurate, but the predictor sets are highly idiographic. This has practical implications for mobile health and just-in-time adaptive interventions. Furthermore, current theories around binge eating need to account for this high between-person variability and broaden the scope of potential antecedent factors. Ultimately, a radical shift from purely nomothetic models to idiographic prediction models and theories is required.

Cognitive Fusion and Emotional Eating among Adolescents with Obesity: A Preliminary Cross-Sectional Study

Cognitive fusion and avoidance are supposed to exert a key role in the development and maintenance of disordered eating behaviors related to obesity, such as emotional eating. A large portion of the research has focused on adult populations, while few data are available on adolescents so far. The current cross-sectional study is intended to explore the association between cognitive fusion, avoidance, and emotional eating in a sample of fifty-six Italian adolescents (13-17 years) with obesity (body mass index > 97th centile). For this purpose, participants attending a 3-week body weight reduction program were assessed using demographical, physical, and clinical data. A multivariate linear regression model was performed in order to preliminarily investigate the predictive role of cognitive fusion on emotional eating, controlling for possible confounding factors. Results showed a significant association between cognitive fusion and emotional eating. Regression revealed that cognitive fusion was a significant contributor for explaining emotional eating (controlling for sex) [R² = 0.551; Adjusted R² = 0.534; F(2,53) = 32.5; p < 0.001]. Even if preliminary, our findings suggest a predictive role of cognitive fusion on emotional eating, and also suggest that cognitive fusion can be considered a key component in understanding and addressing of disordered eating behaviors related to obesity. Future replications are required to expand the sample and collect longitudinal data. Intervention programs for childhood obesity could benefit from this line of research.

Retention, engagement, and binge-eating outcomes: Evaluating feasibility of the Binge-Eating Genetics Initiative study

OBJECTIVE

Using preliminary data from the Binge-Eating Genetics Initiative (BEGIN), we evaluated the feasibility of delivering an eating disorder digital app, Recovery Record, through smartphone and wearable technology for individuals with binge-type eating disorders.

METHODS

Participants (n = 170; 96% female) between 18 and 45 years old with lived experience of binge-eating disorder or bulimia nervosa and current binge-eating episodes were recruited through the Recovery Record app. They were randomized into a Watch (first-generation Apple Watch + iPhone) or iPhone group; they engaged with the app over 30 days and completed baseline and endpoint surveys. Retention, engagement, and associations between severity of illness and engagement were evaluated.

RESULTS

Significantly more participants in the Watch group completed the study (p = .045); this group had greater engagement than the iPhone group (p's < .05; pseudo-R2 McFadden effect size = .01-.34). Overall, binge-eating episodes, reported for the previous 28 days, were significantly reduced from baseline (mean = 12.3) to endpoint (mean = 6.4): most participants in the Watch (60%) and iPhone (66%) groups reported reduced binge-eating episodes from baseline to endpoint. There were no significant group differences across measures of binge eating. In the Watch group, participants with fewer episodes of binge eating at baseline were more engaged (p's < .05; pseudo-R2 McFadden  = .01-.02). Engagement did not significantly predict binge eating at endpoint nor change in binge-eating episodes from baseline to endpoint for both the Watch and iPhone groups.

DISCUSSION

Using wearable technology alongside iPhones to deliver an eating disorder app may improve study completion and app engagement compared with using iPhones alone.

The efficacy of a transdiagnostic emotion regulation skills training in the treatment of binge-eating disorder-Results from a randomized controlled trial

OBJECTIVES

Deficits in emotion regulation (ER) have been shown to be associated with binge-eating disorder (BED). To further clarify the causal nature of this association, we tested whether systematically enhancing ER skills would reduce symptoms of BED.

METHODS

We randomly allocated N = 101 individuals meeting the criteria for BED to a transdiagnostic ER skills training or to a waitlist control condition (WLC). Primary outcome was the reduction in binges during the treatment-vs.-waiting period as assessed with the Eating Disorder Examination (EDE) interview.

RESULTS

Mixed-model ANOVAs indicated that the average pre-to-post decrease in binges assessed with the EDE was significantly greater in the ER skills training condition than in the WLC (d = 0.66). These effects were stable over the 6-month follow-up period (d = 0.72). Remission rates at post/follow-up were 34.4/45.0% in the skills training and 7.5/20.0% in the WLC. Additionally, we found a greater reduction in general eating disorder psychopathology, of food consumption in a bogus taste test and of depression in the ER skills training condition. Moreover, the greater reduction in binge-eating episodes in the training condition was (partially) mediated by a greater increase in ER skills.

CONCLUSIONS

The findings provide further support for the assumed importance of deficits in ER as a maintaining factor and, hence, as a target in the treatment of BED. As ER skills trainings have been shown to also reduce other kinds of psychopathology, they might be considered a promising transdiagnostic add-on component to disorder-specific interventions.

Detecting Mental Health Behaviors Using Mobile Interactions: Exploratory Study Focusing on Binge Eating

BACKGROUND

Binge eating is a subjective loss of control while eating, which leads to the consumption of large amounts of food. It can cause significant emotional distress and is often accompanied by purging behaviors (eg, meal skipping, overexercising, or vomiting).

OBJECTIVE

The aim of this study was to explore the potential of mobile sensing to detect indicators of binge-eating episodes, with a view toward informing the design of future context-aware mobile interventions.

METHODS

This study was conducted in 2 stages. The first involved the development of the DeMMI (Detecting Mental health behaviors using Mobile Interactions) app. As part of this, we conducted a consultation session to explore whether the types of sensor data we were proposing to capture were useful and appropriate, as well as to gather feedback on some specific app features relating to self-reporting. The second stage involved conducting a 6-week period of data collection with 10 participants experiencing binge eating (logging both their mood and episodes of binge eating) and 10 comparison participants (logging only mood). An optional interview was conducted after the study, which discussed their experience using the app, and 8 participants (n=3, 38% binge eating and n=5, 63% comparisons) consented.

RESULTS

The findings showed unique differences in the types of sensor data that were triangulated with the individuals' episodes (with nearby Bluetooth devices, screen and app use features, mobility features, and mood scores showing relevance). Participants had a largely positive opinion about the app, its unobtrusive role, and its ease of use. Interacting with the app increased participants' awareness of and reflection on their mood and phone usage patterns. Moreover, they expressed no privacy concerns as these were alleviated by the study information sheet.

CONCLUSIONS

This study contributes a series of recommendations for future studies wishing to scale our approach and for the design of bespoke mobile interventions to support this population.

A systematic review and meta-analysis of animal models of binge eating - Part 1: Definitions and food/drink intake outcomes

Binge eating involves consuming excessive amounts of food within a discrete period of time and is associated with significant impairments in binge-eating disorder and bulimia nervosa. While research on clinical binge eating has provided valuable aetiological insights, animal models allow for closer examination of environmental, biological, and developmental risk factors. Numerous animal models of binge eating exist and differ widely in operational definitions of bingeing, animal characteristics and methodological parameters. The current review aimed to synthesise the available published evidence on these models. A systematic review of binge definitions in 170 articles found most studies displayed good face validity. Meta-analyses on 150 articles confirmed that the amount of food or drink consumed by animals under binge conditions was larger than that of non-binge conditions across many protocols. The meta-regression revealed species, strain, and sex moderated binge effect size, with the largest effect observed in studies with female animals and mice. Risk of bias assessment identified that improved reporting of allocation, baseline characteristics and outcome assessment is required in future studies.

Shame and eating disorders symptoms: A meta-analysis

OBJECTIVE

Numerous empirical studies and theoretical models posit that shame is a common experience among individuals across the eating disorder spectrum. In this study we aim to investigate the association between shame and eating disorders symptoms using a meta-analytical approach.

METHOD

In this meta-analysis, we synthesized findings from 195 studies to examine the proposed association between shame and eating disorders symptoms. We looked at the associations with both general eating disorders symptoms and with specific eating disorders symptoms (i.e., anorexic, bulimic, and binge-eating symptoms). Moderation analyses testing for the effect of type of shame, type of eating symptoms, clinical status, quality of the study, age, and gender were conducted.

RESULTS

Shame was significantly associated with a medium to large effect size with all types of eating disorders symptoms (rs between .40 and .52). Body shame (r = .55) and shame around eating (r = .59) were more strongly related with eating disorders pathology. Type of eating disorders symptoms did not moderate the relationship between shame and disturbed eating.

DISCUSSION

Overall, the magnitude of the effect size of the association between shame and eating disorders symptoms is a medium to large one. Body shame and shame around eating seem to be the types of shame most closely tied with eating disorders symptoms, suggesting that directly targeting them in interventions might be highly beneficial. Findings highlight current gaps in the literature (e.g., mostly correlational studies, low quality studies) with implications for future research.

Too hot to handle: Mood states moderate implicit approach vs. avoidance tendencies toward food cues in patients with obesity and active binge eating disorder

Patients with binge eating disorder (BED) display recurring episodes of eating large amounts of food in a short period of time, especially during negative mood states. However, the psychological processes linking negative mood to binge eating behavior have not been sufficiently explored. This study investigated the effects of experimentally inducing a negative (sad) mood state upon reaction times in a computerized Approach-Avoidance-Task (AAT) using images of foods and compared to a neutral control procedure in which negative mood was not induced. Differences in reaction times between "pulling" and "pushing away" food cues in the AAT were considered surrogates for fast, automatic (i.e., implicit) preferences ("bias") for either the approach or avoidance of foods. Obese patients with BED (n = 40), weight-matched (obese) individuals (n = 40), and norm-weight controls (n = 29) were asked to approach ("pull") or avoid ("push") images of high- and low-calorie foods following the induction of a negative mood state vs. the neutral control procedure. Sample size was within the common range of previous investigations of the kind. Similar to previous findings, obese patients with BED exhibited an avoidance bias (i.e., faster reaction times in "pushing" compared to "pulling") during the neutral control condition. However, a contrast analysis revealed that negative mood was associated with decreased avoidance bias in obese patients with BED, but not in obese and norm-weight controls. Mood status exerted no effect on BED patients' self-reported (i.e., explicit) ratings of the urge to consume foods. These findings may help to advance current understanding of how negative (sad) mood states may affect binge eating behaviors. Implications of these findings for developing novel treatment approaches are discussed.

Examining emotion regulation in binge-eating disorder

BACKGROUND

Inefficient mechanisms of emotional regulation appear essential in understanding the development and maintenance of binge-eating disorder (BED). Previous research focused mainly on a very limited emotion regulation strategies in BED, such as rumination, suppression, and positive reappraisal. Therefore, the aim of the study was to assess a wider range of emotional regulation strategies (i.e. acceptance, refocusing on planning, positive refocusing, positive reappraisal, putting into perspective, self-blame, other-blame, rumination, and catastrophizing), as well as associations between those strategies and binge-eating-related beliefs (negative, positive, and permissive), and clinical variables (eating disorders symptoms, both anxiety, depressive symptoms, and alexithymia).

METHODS

Women diagnosed with BED (n = 35) according to the DSM-5 criteria and healthy women (n = 41) aged 22-60 years were assessed using: the Eating Attitudes Test-26, the Eating Beliefs Questionnaire-18, the Hospital Anxiety and Depression Scale, the Toronto Alexithymia Scale-20, the Cognitive Emotion Regulation Questionnaire, and the Difficulties in Emotion Regulation Scale. Statistical analyses included: Student t - tests or Mann-Whitney U tests for testing group differences between BED and HC group, and Pearson's r coefficient or Spearman's rho for exploring associations between the emotion regulation difficulties and strategies, and clinical variables and binge-eating-related beliefs in both groups.

RESULTS

The BED group presented with a significantly higher level of emotion regulation difficulties such as: nonacceptance of emotional responses, lack of emotional clarity, difficulties engaging in goal-directed behavior, impulse control difficulties, and limited access to emotion regulation strategies compared to the healthy controls. Moreover, patients with BED were significantly more likely to use maladaptive strategies (rumination and self-blame) and less likely to use adaptive strategies (positive refocusing and putting into perspective). In the clinical group, various difficulties in emotion regulation difficulties occurred to be positively correlated with the level of alexithymia, and anxiety and depressive symptoms. Regarding emotion regulation strategies, self-blame and catastrophizing were positively related to anxiety symptoms, but solely catastrophizing was related to the severity of eating disorder psychopathology.

CONCLUSIONS

Our results indicate an essential and still insufficiently understood role of emotional dysregulation in BED. An especially important construct in this context seems to be alexithymia, which was strongly related to the majority of emotion regulation difficulties. Therefore, it might be beneficial to pay special attention to this construct when planning therapeutic interventions, as well as to the maladaptive emotion regulation strategies self-blame and catastrophizing, which were significantly related to BED psychopathology.

Negative Mood and Food Craving Strength Among Women with Overweight: Implications for Targeting Mechanisms Using a Mindful Eating Intervention

Objectives

When experiencing negative mood, people often eat to improve their mood. A learned association between mood and eating may cultivate frequent food cravings, detracting from health goals. Training in mindful eating may target this cycle of emotion-craving-eating by teaching individuals to manage urges when experiencing negative mood. We examined the impact of a mobile mindful eating intervention on the link between negative mood and food cravings among overweight women.

Methods

In a single-arm trial, participants (n = 64, M age = 46.1 years, M BMI = 31.5 kg/m²) completed ecological momentary assessments of negative mood and food cravings 3 times/day for 3 days pre- and post-intervention, as well as 1-month post-intervention. Using multilevel linear regression, we compared associations between negative mood and food craving strength at pre- vs. post-intervention (model 1) and post-intervention vs. 1-month follow-up (model 2).

Results

In model 1, negative mood interacted with time point (β =  − .20, SE = .09, p = .02, 95% CI [− .38, − .03]) to predict craving strength, indicating that the within-person association between negative mood and craving strength was significantly weaker at post-intervention (β = 0.18) relative to pre-intervention (β = 0.38). In model 2, negative mood did not interact with time point to predict craving strength (β = .13, SE = .09, p = .10, 95% CI − .03, .31]); the association did not significantly differ between post-intervention and 1-month follow-up.

Conclusions

Training in mindful eating weakened the mood-craving association from pre- to post-intervention. The weakened association remained at follow-up. Our findings highlight the mood-craving link as a target-worthy mechanism of mindful eating that should be assessed in clinical trials.

Trial Registration

NCT02694731

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-021-01760-z.

Relationships between nonappearance self-discrepancy, weight discrepancy, and binge eating disorder symptoms

PURPOSE

Self-discrepancy (i.e., perceived differences between one's actual self and personal standards) has been associated with binge eating disorder (BED) symptoms. However, little is known about how weight discrepancy (i.e., the difference between one's actual and ideal weights) interacts with or is distinguished from nonappearance self-discrepancy (discrepancy unrelated to weight or shape) in predicting BED severity. The current study examined how these two forms of discrepancy independently and interactively relate to BED and associated symptoms to elucidate how facets of self-discrepancy may operate to precipitate and maintain BED.

METHODS

Adults with BED (N = 111) completed questionnaires and interviews prior to treatment that assessed self-discrepancy (computerized selves) and weight discrepancy (assessed during the Eating Disorder Examination [EDE]) as predictors of global eating disorder (ED) symptomatology (EDE Global score), depression (Beck Depression Inventory), anxiety (State-Trait Anxiety Inventory), self-esteem (Rosenberg Self-Esteem Scale), and ED-related impairment (Clinical Impairment Assessment).

RESULTS

Multivariate regression models indicated nonappearance self-discrepancy and weight discrepancy were not significantly related to the severity of global ED symptoms, but both independently predicted impairment (ps < 0.05). Nonappearance self-discrepancy, but not weight discrepancy, was also associated with higher depression (p = 0.001), anxiety (p < 0.001), and lower self-esteem (p < 0.001).

CONCLUSION

These findings suggest distinct associations of weight discrepancy and nonappearance self-discrepancy with ED and related symptoms, as well as each of these constructs' relevance to everyday functioning in BED. The results also highlight potential avenues for future research to examine mechanistic pathways by which self-discrepancy influences BED severity.

LEVEL OF EVIDENCE

V, descriptive cross-sectional study.

A Preliminary Exploration of Behaviours Associated with Negative Urgency in Individuals High and Low in Chronic Worry

While chronic worry is typically associated with cautious and harm-avoidant behaviours, there is evidence that people high in chronic worry are characterised by negative urgency (NU), that is, the propensity to act rashly when experiencing negative affect. The present study was a preliminary examination of how rash action and impulsive decision-making manifest for chronic worriers compared to individuals low in worry. In total, 93 participants who endorsed high and low worry and NU responded to open-ended questions about their experience of NU on Amazon Mechanical Turk. Themes were identified using a data-driven approach. Participants high in chronic worry endorsed significantly greater NU compared to those low in worry. However, the types of NU behaviours were similar across participants, with a majority of responses involving initiating interpersonal conflict. Other themes included spending money, excessive eating, alcohol use, and aggressive behaviours. The manifestations of NU were largely consistent with those described in the model of NU. Although individuals higher in chronic worry engaged in NU behaviours to a greater extent, the types of behaviours were similar to those reported by people lower in worry. More research is needed to understand the characteristics of NU-motivated behaviour in individuals high in chronic worry.

Food for mood: Experimentally induced negative affect triggers loss of control over eating in adolescents with low inhibitory control

OBJECTIVE

Loss of control over eating (LOC) is common among adolescents and is associated with negative developmental outcomes. Low self-regulation, and specifically low inhibitory control, is increasingly emphasized as an underlying factor in LOC. However, the specific context in which these capacities fail remains unclear. The affect regulation model proposes that negative affect may trigger LOC; however, research has mostly assessed trait negative affect using questionnaires, whereas measuring state negative affect is needed to determine its triggering role. Therefore, this study examined the interaction between inhibitory control and state negative affect in predicting LOC among adolescents using an experimental mood-induction design.

METHOD

Participants were 50 adolescents (10-18 years; 76% girls) from the general community. Participants first reported on their self-regulatory and inhibitory control capacities. They were then assigned to a sad or neutral mood-induction (using a film clip), followed by a multi-item food buffet from which they could eat as much as they liked. Finally, participants reported on their experience of loss of control while eating.

RESULTS

Inhibitory control (but not self-regulation in general) interacted with the mood-induction to predict LOC. Adolescents with low inhibitory control experienced significantly more LOC, but only in the sad mood condition.

DISCUSSION

The experience of negative affect appears to be an important trigger for LOC in adolescents with low inhibitory control. With a view to prevention and early intervention of LOC, inhibitory control training may be most effective in contexts where adolescents experience high levels of negative affect.

Affect Dysregulation in Context: Implications and Future Directions of Experience Sampling Research on Affect Regulation Models of Loss of Control Eating

Loss of control eating is a core, transdiagnostic eating disorder symptom associated with psychological distress, functional impairment, and reduced quality of life. However, the factors that contribute to persistent loss of control eating despite negative consequences are not fully understood. Understanding the mechanisms that maintain loss of control eating is crucial to advance treatments that interrupt these processes. Affect regulation models of loss of control eating hypothesize that negative emotions trigger loss of control eating, and that loss of control eating is negatively reinforced because it temporarily decreases negative affect. Several variations on this basic affect regulation model have been proposed, including theories suggesting that negative affect decreases during loss of control eating rather than afterwards (escape theory), and that loss of control eating replaces one negative emotion with another that is less aversive (trade-off theory). Experience sampling designs that measure negative affect and eating behavior multiple times per day are optimally suited to examining the nuanced predictions of these affect regulation models in people's everyday lives. This paper critically reviews experience sampling studies examining associations between negative affect and loss of control eating, and discusses the implications for different affect regulation models of loss of control eating. The review concludes by proposing an expanded affect-focused model of loss of control eating that incorporates trait-level individual differences and momentary biological and environmental variables to guide future research. Clinical implications and recommendations are discussed.

Differences in Affective Dynamics Among Eating Disorder Diagnostic Groups

Emotion regulation theories suggest that affect intensity is crucial in the development and maintenance of eating disorders. However, other aspects of emotional experience, such as lability, differentiation, and inertia, are not as well understood. This study is the first to use ecological momentary assessment (EMA) to examine differences in several daily negative affect (NA) indicators among adults diagnosed with anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED). Using EMA data from three large studies, a series of linear mixed models showed that participants in the AN and BN groups experienced significantly greater NA intensity and better emotion differentiation than participants in the BED group. Alternatively, the BN group demonstrated significantly greater NA lability than the AN group and greater NA inertia than the BED group. These results suggest that several daily affective experiences differ among eating disorders diagnostic groups and have implications towards distinct conceptualizations and treatments.

The interplay between self-regulation and affectivity in binge eating among adolescents

Binge eating among adolescents is associated with negative developmental outcomes. From a cognitive perspective, the role of impaired self-regulation is increasingly emphasized as an underlying factor in binge eating, whereas the affect regulation model proposes that affectivity is a key factor in explaining binge eating. Studies combining both perspectives are scarce, but necessary to add to the understanding of this pathological eating behavior. Therefore, the aim of the current study was to investigate unique and joint contributions of both factors in understanding binge eating among adolescents. Participants were 301 adolescents (10-17 years; 67.2% girls; M_age = 13.46 years; SD = 1.99) from the general community. Adolescents self-reported on different types of binge eating episodes (loss of control over eating in general, objective and subjective binge eating in particular), self-regulation (general self-regulation and inhibitory control) and affectivity (positive and negative). The parents were questioned about their children's self-regulatory capacities. Results revealed main effects of self-regulatory capacities (adolescent report) and negative affectivity in predicting objective binge eating. In addition, negative affectivity interacted with self-regulation (parent report) to predict objective binge eating, whereas positive affectivity interacted with self-regulation (adolescent report) to predict subjective binge eating. No significant effects were found for loss of control over eating specifically. Both self-regulation and affectivity each make unique as well as joint contributions to binge eating among adolescents, with results differing across types of binge eating episodes and informants. Theoretical and practical implications are discussed.

Moving beyond self-report data collection in the natural environment: A review of the past and future directions for ambulatory assessment in eating disorders

OBJECTIVE

In recent years, ecological momentary assessment (EMA) has been used to repeatedly assess eating disorder (ED) symptoms in naturalistic settings, which has allowed for increased understanding of temporal processes that potentiate ED behaviors. However, there remain notable limitations of self-report EMA, and with the rapid proliferation of technology there are ever-increasing possibilities to improve ambulatory assessment methods to further the understanding and treatment of EDs. Therefore, the purpose of this review was to (a) systematically review the studies in EDs that have utilized ambulatory assessment methods other than self-report, and (b) provide directions for future research and clinical applications.

METHOD

A systematic literature search of electronic databases was conducted, and data regarding study characteristics and methodological quality were extracted.

RESULTS

The search identified 17 studies that used ambulatory assessment methods to gather objective data, and focused primarily on autonomic functioning, physical activity, and cognitive processes in ED and control groups.

DISCUSSION

Together the literature demonstrates the promise of using a range of ecologically valid ambulatory assessment approaches in EDs, though there remains limited research that has utilized methods other than self-report (e.g., wearable sensors), particularly in recent years. Going forward, there are several technology-enhanced momentary assessment methods that have potential to improve the understanding and treatment of EDs.

Is comfort food actually comforting for emotional eaters? A (moderated) mediation analysis

An important but unreplicated earlier finding on comfort eating was that the association between food intake and immediate mood improvement appeared to be mediated by the palatability of the food, and that this effect was more pronounced for high than for low emotional eaters [26]. This has not yet been formally tested using mediation and moderated mediation analysis. We conducted these analyses using data from two experiments on non-obese female students (n = 29 and n = 74). Mood and eating satisfaction in Study 1, and mood, tastiness and emotional eating in Study 2 were all self-reported. In Study 1, using a sad mood induction procedure, emotional eaters ate more food, and when mood was assessed immediately after food intake, 'eating satisfaction' acted as mediator between food intake and mood improvement (decrease in sadness or increase in happiness). In Study 2, where we measured the difference in actual food intake after a control or a stress task (modified Trier Social Stress Test), and assessed mood during the food intake after stress, we found significant moderated mediation. As expected, there was a significant positive mediation effect of tastiness between food intake and mood improvement in the high emotional eaters, but also a significant negative mediation effect of tastiness between food intake and mood improvement in the low emotional eaters. This suggests that tastiness promotes 'comfort' from food in female emotional eaters, but conflicts in non-emotional eaters with a tendency to eat less when stressed. In conclusion, palatable food may indeed provide comfort specifically for high emotional eaters during eating.

Prospective associations of negative mood and emotion regulation in the occurrence of binge eating in binge eating disorder

Retrospective and experimental data demonstrate the importance of emotion regulation (ER) in the maintenance of binge episodes in binge eating disorder (BED). The current study tested whether mood and ER prospectively influence binge episodes in individuals with BED via ecological momentary assessment (EMA). Individuals with BED (n = 79) completed two weeks of EMA. Each sampling point consisted of a series of questions pertaining to participants' mood, ER, and eating behaviour. Successful application of adaptive ER strategies predicted subsequent abstinence, while rumination predicted subsequent binge episodes. However, neither successful application of adaptive ER, nor maladaptive ER, moderated the association between negative mood and probability of binge episodes. This naturalistic study emphasizes the importance of promoting the successful application of adaptive ER skills and cessation of rumination in treatment interventions designed to decrease the occurrence of binge episodes in BED.

Binge Eating Disorder and Related Features in Bariatric Surgery Candidates

OBJECTIVE

The present study sought to: 1) assess the prevalence of Binge Eating Disorder (BED) and abnormal eating behaviors in bariatric surgery candidates; 2) compare patients with and without BED as regards to eating disturbances, psychological characteristics, and health status; 3) individuate which factors were significantly related to binge eating severity.

METHODS

Sixty-three preoperative patients (17 males and 46 females) were screened by means of an ad hoc socio-demographic schedule, the Rosenberg Self-Esteem Scale, the Eating Disorders Inventory-3, the Binge Eating Scale, and the General Health Questionnaire-28. BED diagnosis was performed through a clinical interview.

RESULTS

BED and disordered eating, such as episodes of binge eating, sense of lack of control over eating and inappropriate compensatory behaviors, appear common in patients undergoing weight loss surgery. Significant differences between BED and non-BED subjects in relation to eating disturbances and psychological characteristics emerged. Multiple regression analysis revealed that only emotional dys-regulation significantly predicted binge eating vulnerability.

CONCLUSION

The recognition of factors involved in the development and maintenance of disordered eating in bariatric patients may support the choice of particular therapeutic strategies and improve bariatric surgery outcome. Further studies on this issue would be useful.

Imagery rescripting in individuals with binge-eating behavior: An experimental proof-of-concept study

OBJECTIVE

Mental imagery is more strongly related to emotions than verbal cognitions. Binge eating is associated with dysfunctional emotional regulation. However, cognitive therapy techniques have focused on verbal cognitions. This proof-of-concept study compares a traditional cognitive therapy technique, cognitive restructuring (CR), with imagery rescripting (IR) in individuals with binge-eating disorder or bulimia nervosa.

METHOD

Thirty-six participants were asked to recall an idiosyncratic mental image of social rejection. They were then randomly assigned to a single session of CR or IR. Ratings of positive and negative emotions, and impact on rational and emotional core beliefs were administered prior to and after imagery recall, after the experimental intervention, and 1 week later. Eating disorder psychopathology was measured before and 1 week after the experimental intervention.

RESULTS

Repeated measures ANOVAs revealed that after the experimental intervention, negative emotions and core beliefs had significantly decreased in CR and IR. Both groups also showed an increase in positive emotions that lasted until 1-week follow-up.

DISCUSSION

This study suggests that CR and IR as an experimental intervention have comparable impact on distress and rational and emotional core beliefs. The feasibility of IR has been demonstrated. The effect of imagery recall on CR needs further investigation.

Distress tolerance across self-report, behavioral and psychophysiological domains in women with eating disorders, and healthy controls

BACKGROUND AND OBJECTIVES

The tendency to engage in impulsive behaviors when distressed is linked to disordered eating. The current study comprehensively examines emotional responses to a distress tolerance task by utilizing self-report, psychophysiological measures (respiratory sinus arrhythmia [RSA], skin conductance responses [SCRs] and tonic skin conductance levels [SCLs]), and behavioral measures (i.e., termination of task, latency to quit task).

METHODS

26 healthy controls (HCs) and a sample of treatment-seeking women with Bulimia Nervosa (BN), Binge Eating Disorder (BED) and Anorexia Nervosa (AN) (N = 106) completed the Paced Auditory Serial Addition Task- Computerized (PASAT-C). Psychophysiological measurements were collected during baseline, PASAT-C, and recovery, then averaged for each time period. Self-reported emotions were collected at baseline, post-PASAT-C and post-recovery.

RESULTS

Overall, we found an effect of Time, with all participants reporting greater negative emotions, less happiness, lower RSA, more SCRs and higher tonic SCLs after completion of the PASAT-C relative to baseline. There were no differences in PASAT-C performance between groups. There was an effect of Group for negative emotions, with women with BN, BED and AN reporting overall higher levels of negative emotions relative to HCs. Furthermore, we found an effect of Group for greater urges to binge eat and lower RSA values among BED, relative to individuals with BN, AN and HCs.

LIMITATIONS

This study is cross-sectional and lacked an overweight healthy control group.

CONCLUSION

During the PASAT-C, individuals with eating disorders (EDs) compared to HCs report higher levels of negative emotions, despite similar physiological and behavioral manifestations of distress.

The assessment of successful emotion regulation skills use: Development and validation of an English version of the Emotion Regulation Skills Questionnaire

Emotion regulation has become an important topic in mental health and psychotherapy research. Skills supposingly relevant for adaptive responses towards emotions include the abilities to be consciously aware of emotions, identify and correctly label emotions, understand what has caused and maintains one’s present emotions, modify the intensity or duration of one's emotions, accept and tolerate undesired emotions, confront situations likely to cue negative emotions, and provide effective self-support when working to cope with challenging emotions. To economically assess these abilities, a self-report measure has been developed in German and validated in various studies. To facilitate the use of the measure in English speaking countries, we have developed and validated an English version of the Emotion Regulation Skills Questionnaire (ERSQ) in a student sample (n = 263) and a sample of individual clinical sample (n = 35). Findings from this study provide significant evidence for the reliability and validity of the ERSQ. Thus, the measure can be used to assess a broad range of important emotion regulation skills in an economic way.

Emotion Regulation in Binge Eating Disorder: A Review

The purpose of the present review is to provide a summary of the research findings on emotion regulation in Binge Eating Disorder (BED). Negative emotions and maladaptive emotion regulation strategies play a role in the onset and maintenance of binge eating in BED. Anger and sadness, along with negative emotions related to interpersonal experiences (i.e., disappointment, being hurt or loneliness), seem to be particularly relevant. Individuals with BED have a tendency to suppress and ruminate on their unwanted emotions, which leads to increased psychopathological thoughts and symptoms. Compared to healthy controls, they use adaptive strategies, such as reappraisal, less frequently. Evidence concerning the causal relation between negative affect and binge eating is inconclusive and still very limited. While experimental studies in a laboratory setting lack ecological validity, ecological momentary assessment studies offer more promise at unraveling the causal relationship between emotions and binge eating. Increases in negative affect are found to be antecedents of binge eating in BED. However, there seems to be less support for the possibility that binge eating serves as a means to alleviate negative affect. Finally, BED seems to be related to other forms of maladaptive emotion regulation strategies, such as substance abuse and self-harm.

Testing predictions of the emotion regulation model of binge-eating disorder

OBJECTIVE

The emotion regulation (ER) model of binge eating posits that individuals with binge-eating disorder (BED) experience more intense emotions and greater difficulties in ER than individuals without BED, leading them to binge eat as a means of regulating emotions. According to this model, individuals with BED should report greater difficulties in ER than their non-BED counterparts, the severity of these difficulties should be positively associated with BED symptoms, and this association should be stronger when individuals experience persistent negative emotions (i.e., depression). Studies examining these hypotheses, however, have been limited.

METHOD

Data were collected from adults meeting the DSM 5 criteria for BED (n = 71; 93% female) and no history of an eating disorder (NED; n =  79; 83.5% female). Participants completed self-report measures of difficulties in ER, eating disorder (ED) psychopathology, and depression.

RESULTS

Individuals with BED reported greater difficulties in ER compared to those with NED. Moreover, difficulties in ER predicted unique variance in binge frequency and ED psychopathology in BED. Depression moderated the association between ER difficulties and binge frequency such that emotion dysregulation and binge frequency were positively associated in those reporting high, but not low, depression levels.

DISCUSSION

The association between difficulties in ER and ED pathology in BED suggests that treatments focusing on improving ER skills may be effective in treating this ED; however, the moderating effect of depression underscores the need for research on individual differences and treatment moderators. These findings suggest the importance of ER in understanding and treating BED.

Predictors of daily life suicidal ideation in adults recently discharged after a serious suicide attempt: A pilot study

The aims of the study are to examine the predictive role of fluctuations in daily life mood, social contexts, and behavior on subsequent suicidal ideation (SI); and to identify clinical and psychological factors associated with the general frequency of SI in a high-risk sample. The sample comprised 42 adults (73.8% female) hospitalized for a suicide attempt. Immediately following hospital discharge, they used Ecological Momentary Assessment for seven consecutive days, providing repeated measures of SI, environmental, contextual, and behavioral factors. Controlling for prior SI, a number of contextual variables were associated with subsequent SI. Being at home or at work were both associated with an increased probability of SI, while being in the home of close others, or in a festive or leisure environment decreased SI probability. Working, passive leisure and inactivity all increased the likelihood of SI. Being alone increased SI while being with close others significantly reduced this risk. Finally, no overall effect for stressful events was found but negative family events specifically were associated with increased likelihood of SI (γ = 0.448, t = 2.255, df = 29, p < 0.05). The findings provide preliminary results regarding proximal environmental and behavioral factors associated with the occurrence of suicidal ideation in a high-risk sample.

Temporal associations between affective instability and dysregulated eating behavior in bulimia nervosa

Prior research suggests that the construct of emotional instability may be salient to bulimia nervosa (BN), but no study to date has used ecological momentary assessment (EMA) to examine its temporal association with binge eating and purging. In the current study, 133 women with DSM-IV BN used portable digital devices to provide multiple daily negative affect (NA) and positive affect (PA) ratings and record eating disorder behaviors over 2 weeks. Two state-of-the art indices quantified affective instability: probability of acute change (PAC), which represents the likelihood of extreme affective increases, and mean squared successive difference (MSSD), which represents average change over successive recordings. For extreme affective change, results revealed that on bulimic behavior days, extreme NA increases were less likely after bulimic behaviors than before them, and extreme increases in PA were more likely after bulimic behaviors than during the same time period on non-bulimic behavior days. However, average NA instability (i.e., MSSD) was (a) greater on bulimic behavior days than non-bulimic behavior days, (b) greater after bulimic behaviors than during the same time period on non-bulimic behavior days, and (c) greater after bulimic behaviors than before them. Results lend support to the notion that bulimic behaviors are negatively reinforcing (i.e., via post-behavior acute affective changes), but also indicate that these behaviors may exacerbate overall affective dysregulation. These findings may improve understanding of BN maintenance and inform the development of novel interventions or refinement of existing treatments.

Emotional Eating, Binge Eating and Animal Models of Binge-Type Eating Disorders

PURPOSE OF REVIEW

The objective of this paper is to review the role that hedonic factors, emotions and self-regulation systems have over eating behaviours from animal models to humans.

RECENT FINDINGS

Evidence has been found to suggest that for some high-risk individuals, obesity/binge eating may develop as an impulsive reaction to negative emotions that over time becomes a compulsive habit. Animal models highlight the neural mechanisms that might underlie this process and suggest similarities with substance use disorders. Emotional difficulties and neurobiological factors have a role in the aetiology of eating and weight disorders. Precise treatments targeted at these mechanisms may be of help for people who have difficulties with compulsive overeating.

Stress, overeating, and obesity: Insights from human studies and preclinical models

Eating disorders and obesity have become predominant in human society. Their association to modern lifestyle, encompassing calorie-rich diets, psychological stress, and comorbidity with major diseases are well documented. Unfortunately the biological basis remains elusive and the pharmacological treatment inadequate, in part due to the limited availability of valid animal models. Human research on binge eating disorder (BED) proves a strong link between stress exposure and bingeing: state-levels of stress and negative affect are linked to binge eating in individuals with BED both in laboratory settings and the natural environment. Similarly, classical animal models of BED reveal an association between acute exposure to stressors and binging but they are often associated with unchanged or decreased body weight, thus reflecting a negative energy balance, which is uncommon in humans where most commonly BED is associated with excessive or unstable body weight gain. Recent mouse models of subordination stress induce spontaneous binging and hyperphagia, altogether more closely mimicking the behavioral and metabolic features of human BED. Therefore the translational relevance of subordination stress models could facilitate the identification of the neurobiological basis of BED and obesity-associated disease and inform on the development of innovative therapies.

User profiles of an electronic mental health tool for ecological momentary assessment: MEmind

Ecological momentary assessment (EMA) is gaining importance in psychiatry. This article assesses the characteristics of patients who used a new electronic EMA tool: the MEmind Wellness Tracker. Over one year, 13811 adult outpatients in our Psychiatry Department were asked to use MEmind. We collected information about socio-demographic data, psychiatric diagnoses, illness severity, stressful life events and suicidal thoughts/behavior. We compared active users (N = 2838) and non-active users (N = 10,973) of MEmind and performed a Random Forest analysis to assess which variables could predict its use. Univariate analyses revealed that MEmind-users were younger (42.2 ± 13.5 years versus 48.5 ± 16.3 years; χ²  = 18.85; P < 0.001) and more frequently diagnosed with anxiety related disorders (57.9% versus 46.7%; χ²  = 105.92; P = 0.000) than non-active users. They were more likely to report thoughts about death and suicide (up to 24% of active users expressed wish for death) and had experienced more stressful life events than non-active users (57% versus 48.5%; χ²  = 64.65; P < 0.001). In the Random Forest analysis, 31 variables showed mean decrease accuracy values higher than zero with a 95% confidence interval (CI), including sex, age, suicidal thoughts, life threatening events and several diagnoses. In the light of these results, strategies to improve EMA and e-Mental Health adherence are discussed.

Developing an Acceptance-Based Behavioral Treatment for Binge Eating Disorder: Rationale and Challenges

Binge eating disorder (BED), characterized by recurrent eating episodes in which individuals eat an objectively large amount of food within a short time period accompanied by a sense of loss of control, is the most common eating disorder. While existing treatments, such as cognitive behavioral therapy (CBT), produce remission in a large percentage of individuals with BED, room for improvement in outcomes remains. Two reasons some patients may continue to experience binge eating after a course of treatment are: (a) Difficulty complying with the prescribed behavioral components of CBT due to the discomfort of implementing such strategies; and (b) a lack of focus in current treatments on strategies for coping with high levels of negative affect that often drive binge eating. To optimize treatment outcomes, it is therefore crucial to provide patients with strategies to overcome these issues. A small but growing body of research suggests that acceptance-based treatment approaches may be effective for the treatment of binge eating. The goal of the current paper is to describe the development of an acceptance-based group treatment for BED, discuss the structure of the manual and the rationale and challenges associated with integrating acceptance-based strategies into a CBT protocol, and to discuss clinical strategies for successfully implementing the intervention.

A pilot open series of lamotrigine in DBT-treated eating disorders characterized by significant affective dysregulation and poor impulse control

BACKGROUND

There is little effective psychopharmacological treatment for individuals with eating disorders who struggle with pervasive, severe affective and behavioral dysregulation.

METHODS

This pilot open series evaluated lamotrigine, a mood stabilizer, in the treatment of patients with eating disorders who did not respond adequately to antidepressant medications. Nine women with anorexia nervosa- or bulimia nervosa-spectrum eating disorders in partial hospital or intensive outpatient dialectical behavior therapy (DBT)-based eating disorder treatment took lamotrigine for 147 ± 79 days (mean final dose = 161.1 ± 48.6 mg/day). Participants completed standardized self-report measures of emotion dysregulation and impulsivity after lamotrigine initiation and approximately biweekly thereafter. Mood and eating disorder symptomatology were measured at lamotrigine initiation and at time of final assessment.

RESULTS

Lamotrigine and concurrent DBT were associated with large reductions in self-reported affective and behavioral dysregulation (ps < 0.01). Eating disorder and mood symptoms decreased moderately.

CONCLUSIONS

Although our findings are limited by the confounds inherent in an open series, lamotrigine showed initial promise in reducing emotional instability and behavioral impulsivity in severely dysregulated eating-disordered patients. These preliminary results support further investigation of lamotrigine for eating disorders in rigorous controlled trials.

Exploring the mind's eye: Contents and characteristics of mental images in overweight individuals with binge eating behaviour

Mental images play a role in various mental disorders and are strongly associated with emotions. Negative emotions and their regulation are important in eating disorders. However, research on mental imagery in eating disorders is still scarce. We investigated mental images and their relation to distress and eating disorder psychopathology in individuals with binge eating behaviour. Content and characteristics of mental images and their relation to psychopathology of 21 individuals with binge eating behaviour, 19 mixed patient controls and 21 healthy controls have been assessed with a semi-structured interview. Occurrence and vividness of food-related images did not differ between groups. However they were experienced as more distressing and distracting and more difficult to control by eating disordered patients. Body-related mental images were less associated with desire to eat than expected. Mental images of social rejection were experienced as more vivid by both clinical groups and caused desire to eat in individuals with binge eating behaviour. Mental images are relevant in binge eating behaviour, but with different patterns regarding concomitant distress and eating disorder psychopathology. As transdiagnostic mental images of social rejection are relevant for individuals with binge eating behaviour, research on imagery based techniques in eating disorders seems promising.

Emotional Eating Is Not What You Think It Is and Emotional Eating Scales Do Not Measure What You Think They Measure

In eating research, it is common practice to group people into different eater types, such as emotional, external and restrained eaters. This categorization is generally based on scores on self-report questionnaires. However, recent studies have started to raise questions about the validity of such questionnaires. In the realm of emotional eating, a considerable number of studies, both in the lab and in naturalistic settings, fail to demonstrate increased food intake in emotional situations in self-described emotional eaters. The current paper provides a review of experimental and naturalistic studies investigating the relationships between self-reported emotional eater status, mood, and food consumption. It is concluded that emotional eating scales lack predictive and discriminative validity; they cannot be assumed to measure accurately what they intend to measure, namely increased food intake in response to negative emotions. The review is followed by a discussion of alternative interpretations of emotional eating scores that have been suggested in the past few years, i.e., concerned eating, uncontrolled eating, a tendency to attribute overeating to negative affect, and cue-reactive eating.

Emotion regulation difficulties in binge eating disorder with and without the overvaluation of weight and shape

The objective of this study was to examine the relationship between overvaluation of weight/shape ('overvaluation') and emotion regulation (ER) difficulties among women with binge eating disorder (BED) symptoms. Four groups of women were recruited from a community-based sample and compared on ER difficulties: individuals with probable BED with (n=102) and without (n=72) overvaluation, and non-binge eating obese (n=40) and healthy-weight (n=40) control participants. Data for patients with a formal diagnosis of BED receiving treatment from a previous study were included for numerical comparative purposes. Women with probable BED and overvaluation reported significantly greater ER difficulties than all other groups and had similar levels of ER difficulties to BED patients. Women with probable BED in the absence of overvaluation were comparable to the obese control group on total ER difficulties and the majority of the ER difficulties subscales. The findings provide further evidence for the clinical significance of overvaluation among individuals with BED symptomatology. BED in the absence of overvaluation does not appear to align with current models of the disorder in which ER difficulties are viewed as a core etiological mechanism. Further research is needed to elucidate the status of this presentation.

Stress-induced eating in women with binge-eating disorder and obesity

The purpose of the current study was to investigate stress-induced eating in women with binge-eating disorder (BED) and obesity. Three groups of women [obese with BED (n=9); obese non-BED (n=11); and normal weight (NW) non-BED (n=12)], rated their levels of hunger and psychological distress before and after completing the Trier Social Stress Test, followed by food anticipation and then consumption of their preferred snack food. We differentiated between the motivational and hedonic components of eating by measuring the amount of food participants poured into a serving bowl compared to the amount consumed. Stress did not affect poured and consumed calories differently between groups. Across all subjects, calories poured and consumed were positively correlated with post-stress hunger, but calories poured was positively correlated with post-stress anxiety and negative affect. These results indicate that stress-related psychological factors may be more strongly associated with the motivational drive to eat (i.e. amount poured) rather than the hedonic aspects of eating (i.e. amount consumed) for women in general. Exploratory correlation analyses per subgroup suggest that post-stress hunger was positively associated with calories poured and consumed in both non-BED groups. In the obese BED group, calories consumed was negatively associated with dietary restraint and, although not significantly, positively associated with stress-induced changes in anxiety.These findings suggest that stress-induced snacking in obese BED women may be influenced by psychological factors more so than homeostatic hunger mechanisms. After controlling for dietary restraint and negative affect, the NW non-BED women ate a greater percentage of the food they poured than both obese groups, suggesting that obesity may be associated with a heightened motivational drive to eat coupled with a reduction in hedonic pleasure from eating post-stress. Further studies that incorporate novel approaches to measuring the motivational versus hedonic aspects of stress-induced eating may expose nuanced eating behaviors that differentiate BED and obesity. If confirmed, our findings would support prevention and treatment strategies that target subsets of women based on obesity and BED status.

Reciprocal associations between negative affect, binge eating, and purging in the natural environment in women with bulimia nervosa

Although negative affect (NA) has been identified as a common trigger for bulimic behaviors, findings regarding NA following such behaviors have been mixed. This study examined reciprocal associations between NA and bulimic behaviors using real-time, naturalistic data. Participants were 133 women with bulimia nervosa (BN) according to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders who completed a 2-week ecological momentary assessment protocol in which they recorded bulimic behaviors and provided multiple daily ratings of NA. A multilevel autoregressive cross-lagged analysis was conducted to examine concurrent, first-order autoregressive, and prospective associations between NA, binge eating, and purging across the day. Results revealed positive concurrent associations between all variables across all time points, as well as numerous autoregressive associations. For prospective associations, higher NA predicted subsequent bulimic symptoms at multiple time points; conversely, binge eating predicted lower NA at multiple time points, and purging predicted higher NA at 1 time point. Several autoregressive and prospective associations were also found between binge eating and purging. This study used a novel approach to examine NA in relation to bulimic symptoms, contributing to the existing literature by directly examining the magnitude of the associations, examining differences in the associations across the day, and controlling for other associations in testing each effect in the model. These findings may have relevance for understanding the etiology and/or maintenance of bulimic symptoms, as well as potentially informing psychological interventions for BN.

The association between emotions and eating behaviour in an obese population with binge eating disorder

There is utility in understanding the antecedents of binge eating (BE), with a view to explaining poorer weight loss treatment responses in this subgroup. A systematic review was completed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with the aim of exploring associations between emotions and eating behaviour in a population affected by obesity and binge eating disorder (BED). A comprehensive literature search of four electronic databases (2004-2014) yielded 15 studies for inclusion. Included studies performed poorly on data quality analysis with respect to controlling for confounding variables, and sample size. Included papers largely focused on negative emotions as antecedents of BE; depression was consistently associated with a BED-obese classification and BE. Negative mood, sadness, tension and instability of emotions were found to be antecedents of BE in an adult BED-obese sample. However, findings were mixed regarding the role of stress, anger and positive emotions within the BED-obese population. Recommendations are presented for the identification of BED, and ecologically valid experimental designs that further understanding of the complex and varied emotions that associate with BE. The implications of these and other limitations for both researchers and practitioners are discussed. The paper concludes with recommendations for future research alongside suggestions for practitioners. © 2015 World Obesity.

Difficulties in emotion regulation in patients with eating disorders

BACKGROUND

A defining characteristic of eating disorders (EDs) is difficulty with emotion regulation (ER). Previous research indicates that ED subtypes demonstrate differing ER difficulties. Specifically, individuals with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) show greater impairment in their ability to regulate emotions in areas such as achieving goals while upset, reacting impulsively to distress, and effectively using coping strategies, as compared to those with Binge Eating Disorder (BED). However, limited research includes the diagnostic category of Eating Disorder, Not Otherwise Specified (EDNOS). The aim of this study was to better understand ER difficulties for all ED diagnoses, especially EDNOS. It was hypothesized that patients with EDs will demonstrate similar ER difficulties as psychiatric patients without EDs and that patients with EDNOS will be similar in their total level of ER difficulties but will differ in their specific types of difficulties in ER as compared to patients with other EDs.

METHODS

Participants included 404 adults presenting to an inpatient psychiatric hospital. Psychiatric diagnoses, including EDs, were determined using the Structured Clinical Interview for DSM Disorders. Differences in specific and overall difficulties with ER were examined across psychiatric patients using the multidimensional Difficulties in Emotion Regulation Scale.

RESULTS

Results of this study indicate that individuals with EDs have greater ER difficulties in most domains of ER and that those with BED and EDNOS demonstrate the most significant differences in ER as compared to psychiatric patients without EDs. Additionally, it was found that ED subtypes typically did not differ in terms of specific difficulties in ER. One exception emerged indicating that individuals with BED demonstrated significantly greater difficulty on the Limited Access to Emotion Regulation Strategies subscale as compared to those with EDNOS.

CONCLUSIONS

Researchers were able to clarify difficulties in ER across ED diagnoses. Results highlight the importance of providing ER skills training for patients with EDs, particularly those with BED and EDNOS, and give insight into the specific areas of ER that may be important for these patients to focus on throughout recovery.

Set-shifting abilities, mood and loss of control over eating in binge eating disorder: An experimental study

Executive functions play an important role in problem-solving and self-control. Set-shifting is an aspect of executive functioning and represents cognitive flexibility. The inability to control eating in Binge Eating Disorder (BED) may imply deficits in set-shifting which could be exacerbated by negative mood and depressive symptoms. The aim of the study was to test whether there is a causal relationship between set-shifting ability, changes in mood and loss of control over eating in BED. Seventy-five participants diagnosed with BED were randomly assigned to a negative or neutral mood induction. Set-shifting abilities, depressive symptoms, current mood and loss of control over eating were assessed. Having depressive symptoms and poorer set-shifting abilities resulted in a more negative mood after a negative mood induction, whereas this was not observed in the neutral mood induction. Post-hoc analyses revealed that individuals with poorer set-shifting abilities and more changes in negative mood, experienced more feelings of loss of control over eating than individuals whose set-shifting abilities were better and whose mood did not change. The results suggest that both depressive symptoms and deficits in set-shifting abilities may decrease an individual's ability to handle negative affect and increase loss of control over eating in individuals with BED.

Testing the cognitive-behavioural maintenance models across DSM-5 bulimic-type eating disorder diagnostic groups: a multi-centre study

The original cognitive-behavioural (CB) model of bulimia nervosa, which provided the basis for the widely used CB therapy, proposed that specific dysfunctional cognitions and behaviours maintain the disorder. However, amongst treatment completers, only 40-50 % have a full and lasting response. The enhanced CB model (CB-E), upon which the enhanced version of the CB treatment was based, extended the original approach by including four additional maintenance factors. This study evaluated and compared both CB models in a large clinical treatment seeking sample (N = 679), applying both DSM-IV and DSM-5 criteria for bulimic-type eating disorders. Application of the DSM-5 criteria reduced the number of cases of DSM-IV bulimic-type eating disorders not otherwise specified to 29.6 %. Structural equation modelling analysis indicated that (a) although both models provided a good fit to the data, the CB-E model accounted for a greater proportion of variance in eating-disordered behaviours than the original one, (b) interpersonal problems, clinical perfectionism and low self-esteem were indirectly associated with dietary restraint through over-evaluation of shape and weight, (c) interpersonal problems and mood intolerance were directly linked to binge eating, whereas restraint only indirectly affected binge eating through mood intolerance, suggesting that factors other than restraint may play a more critical role in the maintenance of binge eating. In terms of strength of the associations, differences across DSM-5 bulimic-type eating disorder diagnostic groups were not observed. The results are discussed with reference to theory and research, including neurobiological findings and recent hypotheses.