Bulimia: an analysis of moods and behavior

Distress tolerance in the eating disorders

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

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

Mood state effects of chocolate

BACKGROUND

Chocolate consumption has long been associated with enjoyment and pleasure. Popular claims confer on chocolate the properties of being a stimulant, relaxant, euphoriant, aphrodisiac, tonic and antidepressant. The last claim stimulated this review.

METHOD

We review chocolate's properties and the principal hypotheses addressing its claimed mood altering propensities. We distinguish between food craving and emotional eating, consider their psycho-physiological underpinnings, and examine the likely 'positioning' of any effect of chocolate to each concept.

RESULTS

Chocolate can provide its own hedonistic reward by satisfying cravings but, when consumed as a comfort eating or emotional eating strategy, is more likely to be associated with prolongation rather than cessation of a dysphoric mood.

LIMITATIONS

This review focuses primarily on clarifying the possibility that, for some people, chocolate consumption may act as an antidepressant self-medication strategy and the processes by which this may occur.

CONCLUSIONS

Any mood benefits of chocolate consumption are ephemeral.

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

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

Can collaboration between education and health professionals improve the identification and referral of young people with eating disorders in schools? A pilot study

In this pilot study, a number of different methods of identifying young people with eating disorders in schools were compared. Pupils aged 16-18 years from 3 schools in the South West of the UK participated (389 boys and 374 girls in total). A self-report questionnaire (EDE-Q) was found to be the most effective method of case identification. However, very few of these cases accepted the offer of help and it was strongly suspected that other cases went undetected despite teacher, parent and school nurse guidance. Implications for future early intervention studies are discussed.

Expositionsverfahren in der Behandlung der Bulimia nervosa

Zusammenfassung. Theoretischer Hintergrund: In der Behandlung von Bulimia nervosa erwiesen sich kognitiv-verhaltenstherapeutische Verfahren als besonders wirksam. Expositions- bzw. Konfrontationsverfahren gewannen dabei in den letzten Jahren zunehmend an Bedeutung. Fragestellung: Untersuchung der Wirksamkeit eines spezifischen kognitiv-verhaltenstherapeutischen Intensivansatzes in der stationären Behandlung von Bulimia nervosa. Methode: Schwerpunkte dieses Ansatzes waren cue-exposure, Ernährungs- und Figur- bzw. Videokonfrontationen. Einer stationären Intensivphase (3-4 Wochen) schloss sich eine ambulante 6-wöchige Selbstmanagementphase an (40 Therapieeinheiten pro Person für beide Phasen zusammen). Eine Vorstudie an 13 Patientinnen gab Hinweise auf die Wirksamkeit des Verfahrens (Vergleich: Vor Aufnahme und ein Jahr nach Abschuss der Behandlung). Die Hauptstudie (73 Patientinnen) wurde ohne wesentliche Änderung der Behandlungsmethode in einem 3-Messzeitpunkte-Design (Aufnahme, 6 Wochen nach Behandlungsende und 1-Jahres-Follow-Up) durchgeführt. Messvariablen waren Anzahl der Essanfälle, Body Mass Index sowie Essstörungssymptomatik (Eating Disorder Inventory - EDI, Fragebogen zum Essverhalten - FEV) und allgemeine Psychopathologie (Symptom-Check-List-90-R; Beck Depression Inventory). Ergebnisse: Bedeutsame Verbesserungen ergaben sich sowohl 6 Wochen nach Ende der Therapie als auch zum 1-Jahres-Follow-Up. Patientinnen der Hauptstudie reduzierten ihre wöchentlichen Essanfälle von 12.27 auf 2.45 (post) und 4.27 (1-Jahres-Follow-Up). Auch in sämtlichen Merkmalen der Essstörungssymptomatik (EDI, FEV) sowie in den SCL-90-Skalen und dem BDI fanden sich signifikante Verbesserungen. 48% hatten nach einem Jahr weniger als zwei Essanfälle pro Woche, was mit den Patientenratings einer “(sehr) guten Besserung“ (49.3%) korrespondierte. Schlussfolgerung: Der untersuchte Therapieansatz an stationären Patientinnen erwies sich einem zuvor erfolgreich getesteten Ansatz an weniger stark beeinträchtigten ambulanten Patientinnen als gut vergleichbar. Auf Grund der sehr guten Erfolge bei einem hohen Anteil der Patientinnen wird diskutiert, ob Ansätze wie der hier untersuchte eine Alternative zu langdauernden ambulanten Therapien und stationären Breitbandprogrammen darstellen.

Comorbidité entre les troubles du comportement alimentaire et les troubles anxieux Première partie : revue méthodologique

The objective of our work is to conduct a critical literature review on studies assessing the prevalence of anxiety disorders (AD) in subjects with eating disorders (ED) (anorexia nervosa and bulimia nervosa). In the first part (this paper), we will discuss methodological issues relevant to comorbidity studies between ED and AD.

METHOD

We performed a manual and computerised search (Medline) for all published studies on comorbidity between ED and AD, limiting our search to the 1985-2002 period, in order to get sufficiently homogeneous diagnostic criteria for both categories of disorders (most often RDC, DSM III, DSM Ill-R, or DSM IV criteria).

RESULTS

We review methodological issues regarding population sources, general methodological procedures, diagnostic criteria for ED and AD, diagnostic instruments, age of subjects and course of the eating disorder.

DISCUSSION

We give implications for reviewing the results of published studies and planing future research.

Emotionsbedingtes Essverhalten: Die Bedeutung der Emotionen

Zusammenfassung. Wirkungen von Emotionen auf das Essverhalten variieren in Abhängigkeit von Person- und Emotionsmerkmalen. Bisherige Untersuchungen waren größtenteils auf den Einfluss von Personmerkmalen gerichtet. Sie zeigten, dass ein gezügelter sowie ein emotionaler Ess-Stil zu gesteigerter Nahrungsaufnahme bei negativen Emotionen prädisponieren. Weitere Untersuchungen verweisen auf den Einfluss von Emotionsmerkmalen wie Intensität und Valenz. Der vorliegende Beitrag fasst den Forschungsstand zusammen und unterteilt die Wirkungen von Emotionen auf das Essverhalten in fünf Varianten, die sich durch definierte Person- und Emotionsmerkmale vorhersagen lassen: emotionale Steuerung der Nahrungswahl, emotionale Hemmung des Essverhaltens, emotionale Enthemmung gezügelten Essverhaltens, emotional-instrumentelles Essverhalten und emotionkongruente Modulation des Essverhaltens.

Effects of negative mood induction and impulsivity on self-perceived emotional eating

OBJECTIVE

The current study investigates the influence of negative mood induction and impulsivity on self-perceptions with respect to emotional eating. Negative affect as well as high impulsivity was expected to increase levels of self-perceived emotional eating.

METHOD

College students who were high versus low in impulsivity were assigned randomly to either a negative (failure on a quiz) or a neutral mood induction. Their levels of self-perceived emotional eating were measured after and before mood induction.

RESULTS

Negative affect appeared to enhance the level of self-perceived emotional eating significantly (p < .01). There was no statistically significant effect of impulsivity. The interaction effect of affect and impulsivity approached significance (p = .08), indicating that highly impulsive subjects compared with subjects low in impulsivity were more strongly influenced by negative affect in self-perceived emotional eating.

DISCUSSION

Negative affect substantially influences self-perceptions in terms of emotional eating, which is relevant for both prevention and treatment.

Cognitive-behavioral theories of eating disorders

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

Mood patterns and variations associated with personality disorder pathology

This study examined mood and mood variation in relation to varying forms and degrees of personality disorder (PD) pathology. Mood experiences of 98 psychotropic medication-free individuals were repeatedly assessed over a 4-day period. Persons with PDs (n = 57) generally displayed neutral to moderately positive moods; however, overall mood valence was less positive when compared to those without PDs (n = 41). Mood ratings demonstrated moderate covariations with anxious-fearful (A-F) PD traits but little or no association with erratic-emotional-dramatic (E-D) and odd-eccentric (O-E) PD traits once common variance among PD dimensions was removed. For PD diagnostic categories, the presence of avoidant and/or depressive PDs was most strongly associated with negative mood. When dimensional scores based on specific PD trait features were considered, avoidant, depressive, borderline, passive-aggressive, obsessive-compulsive, dependent, paranoid, and schizoid PD traits demonstrated the most reliable associations with negative mood. Apart from borderline PD features, traits associated with other E-D cluster PDs displayed little or no associations with mood quality. Consistent with previous research, mood variability emerged as an internally consistent and stable individual difference variable. Mood variability, however, was not generally associated with PD diagnostic categories or traits. Implications of this study's findings are considered in relation to the conceptual modeling of PDs.

Negative feelings and the desire to eat in bulimia nervosa

This study examines a broad range of negative feelings as possible antecedents of binge eating in bulimia nervosa (BN). Another goal is to explore the connection between negative feelings and the desire to eat as recorded continuously during two consecutive days. This is the first study comparing data from BN patients with a relevant clinical control group. Forty female BN patients, 40 female panic disorder (PD) patients, and 40 healthy women continuously recorded their feelings and the desire to eat while in their natural environment. Both patient groups reported more negative feelings than the healthy controls. BN patients had higher within-subject correlations between most negative feelings and the desire to eat than the two control groups. BN patients rated most feelings more negatively in the hour prior to binge eating than during the rest of the day. BN patients' general mood state worsened after binge eating but returned to prebinge levels after purging. The study provides additional evidence that unspecific negative feelings play an important role in the context of binge-eating behavior in BN.

An evaluation of affect and binge eating

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

Threat processing in women with bulimia

Cognitive-behavioral treatments are the most commonly used approaches for bulimia nervosa. However, these treatments tend to produce only moderate remission rates. Therefore, it is useful to consider how experimental cognitive approaches can help to revise current cognitive-behavioral models of bulimia. Information processing models highlight the role of attentional biases and schema avoidance in the etiology and maintenance of pathology. This review considers how these processes relate to bulimia. In particular, a growing body of evidence suggests that bulimic behaviors may function to "block" aversive self-awareness. Blocking behaviors also feature strongly in other impulsive disorders. This review considers the relationship between bulimia and impulsivity, and discusses whether the functions of the two behaviors are the same. The clinical implications and future research needs that arise from this literature are discussed.

Similarities and differences between Caucasian and African American college women on eating and dieting expectancies, bulimic symptoms, dietary restraint, and disinhibition

OBJECTIVE

To clarify race differences in eating disorder risk factors and symptoms, by comparing Caucasian and African American samples on the factor structures, intercorrelations, and mean levels of endorsement on a set of risk and symptom measures.

METHOD

A sample of 300 Caucasian and 200 African American undergraduates completed measures of eating and thinness/dieting expectancies, the Three-Factor Eating Questionnaire (TFEQ), and the BULIT.

RESULTS

The factor structures of each measure were invariant across race. Intercorrelations among the measures generally did not differ across race. On the three expectancy measures predictive of symptomatology, two of three scales of the TFEQ, and the BULIT, African American women had lower mean scores than Caucasian women. Socioeconomic status did not account for the results: in this sample, it was unrelated to race and correlated with only 1 of 20 measures.

DISCUSSION

The factor-based meaning of these measures appears to be consistent across race. The measures correlate similarly across race, suggesting that the risk process may be similar for both races, but African American women endorsed significantly fewer risk factors and fewer symptoms.

Validation of eating and dieting expectancy measures in two adolescent samples

OBJECTIVE

To demonstrate the validity of two measures of eating and dieting expectancies (The Eating Expectancy Inventory [EEI] and the Thinness and Restricting Expectancy Inventory, [TREI]) for use with adolescents.

METHOD

Seventh (N = 392) and tenth graders (N = 300) completed the Bulimia Test-Revised (BULIT-R), the Eating Disorder Inventory (EDI-II), and two factors of the Three-Factor Eating Questionnaire (TFEQ).

RESULTS

Findings replicated for the two adolescent samples. The expectancy that thinness leads to overgeneralized life improvement correlated with measures of "successful" dieting, dieting plus disinhibition, and bulimic symptomatology. Expectancies for negative reinforcement from eating (e.g., eating helps manage negative affect and alleviate boredom) correlated with dieting plus disinhibition and bulimic symptoms, but not with successful dieting. Negative reinforcement from eating and reinforcement from thinness expectancies accounted for different bulimic symptom variance than that accounted for by the personality factors of perfectionism, interpersonal distrust, and ineffectiveness.

DISCUSSION

Results were consistent with prior work on college and clinical samples, thus supporting use of the expectancy measures with adolescents.

Causes of eating disorders

Anorexia nervosa and bulimia nervosa have emerged as the predominant eating disorders. We review the recent research evidence pertaining to the development of these disorders, including sociocultural factors (e.g., media and peer influences), family factors (e.g., enmeshment and criticism), negative affect, low self-esteem, and body dissatisfaction. Also reviewed are cognitive and biological aspects of eating disorders. Some contributory factors appear to be necessary for the appearance of eating disorders, but none is sufficient. Eating disorders may represent a way of coping with problems of identity and personal control.

Does binge eating play a role in the self-regulation of moods?

Self-reported emotional experiences and eating behaviors were studied in college students in an attempt to determine what types of emotional experiences precede and follow binge eating and how specific types of compensatory behaviors modify these experiences. First-year male and female students (N=390) were surveyed for depression, anxiety, health status, life satisfaction, and eating attitudes (EAT-26). Those reporting recurrent binge eating episodes were asked to describe their emotional feelings before and after bingeing and before and after compensatory activities. EAT-26 scores corresponding to scores previously reported for eating disordered patients were found in 9.7% of students. Binge eating was nearly twice as frequent among females (16.4%) as males (8.6%). Among females, positive relationships were found between specific EAT-26 factors scores and both anxiety and depression scores. The emotional antecedents and consequences of binge eating and of compensatory activities were compared in three sub-groups of individuals who reported recurrent bingeing with loss of self-control during binges. The three sub-groups consisted of individuals who reported, 1) bingeing without engaging in compensatory activities, 2) bingeing and compensating by means other than vomiting (fasting, exercising, or use of laxatives or diuretics), and 3) bingeing and compensating by vomiting. Regardless of the type of activity, those individuals who engaged in compensatory activities reported greater negative affect preceding binge episodes than those who did not compensate. In addition, contrary to expectations, negative affect did not decrease, but instead increased significantly, following binge episodes and decreased immediately before and after compensatory activities.

Emotions and eating in everyday life

This field study assessed emotional states experienced in everyday life and examined the subjective motivation to eat associated with these emotional states. Twenty-three female subjects rated their momentary emotional state and motivation to eat on 6 consecutive days at 11:00a.m., 2:00p.m., 5:00p.m., 8:00p.m. and 11:00p.m. A cluster analysis of the resulting 634 emotion profiles revealed three types of emotional states characterized by the labels "Anger-dominance", "Tension/Fear" and "Relaxation/Joy". A fourth cluster showing generally low levels of emotions was labelled "Unemotional state". Most of the self-rated motivations to eat were increased during periods of negative emotions. During negative emotions a heightened tendency to cope with these emotions through eating and more intense bodily symptoms of hunger were also reported. No differences in motivations to eat were found between the two negative emotion clusters or between relaxation/joy and the unemotional state. Results indicate the presence of "emotionally instrumental eating" in a non-clinical population under real life conditions. Physiological correlates of negative emotional states may be involved in emotionally instrumental eating.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Anxiety disorders in anorexia nervosa and bulimia nervosa: co-morbidity and chronology of appearance

The objectives of the study were to assess lifetime prevalence of specific anxiety disorders, and their age of onset relative to that of eating disorders (ED), in a French sample of patients with anorexia nervosa (AN) or bulimia nervosa (BN). We assessed frequencies of seven anxiety disorders and childhood histories of separation anxiety disorder among 63 subjects with a current DSM-IV diagnosis of an ED, using the Composite International Diagnostic Interview (CIDI). Eighty-three percent of subjects with AN and 71% of those with BN had at least one lifetime diagnosis of an anxiety disorder. By far, the most frequent was social phobia (55% of the anorexics and 59% of the bulimics). When present, the co-morbid anxiety disorder had predated the onset of the ED in 75% of subjects with AN, and 88% of subjects with BN. Our results are consistent with those of studies conducted in other countries, and show that an anxiety disorder frequently exists before an ED. This has to be taken in consideration for successful treatment of patients with AN or BN.

DISSOCIATION, COMORBIDITY OF DISSOCIATIVE DISORDERS, AND CHILDHOOD ABUSE IN A COMMUNITY SAMPLE OF WOMEN WITH CURRENT AND PAST BULIMIA

Dissociation and childhood sexual abuse were examined in a community sample of current bulimics (N=47), past bulimics (N=29), and non-bulimic controls (N=37). All respondents completed questionnaires requesting information relating to bulimia, dissociation, and incidence and severity of childhood sexual abuse. Participants scoring high on the measure of dissociation (N=21) were further assessed with a structured clinical interview to determine the proportion who would fulfill the formal criteria for a DSM-IV dissociative disorder. Results indicated that dissociation was highest among current bulimics, and that past bulimics had lower levels of dissociation than current bulimics (although higher than non-bulimic controls). However, there was no association between level of dissociation and incidence of reported childhood sexual abuse. In addition, the incidence of childhood sexual abuse was no higher among bulimics than among the general population – although the severity of the abuse was reported to have been higher. The severity of self-reported childhood sexual abuse was also found to be higher among current bulimics than among past bulimics. Comorbidity of DSM-IV dissociative disorders among current bulimics was found to be 10%.

Shame and guilt in women with eating-disorder symptomatology

The relationship of shame and guilt to eating-disorder symptomatology was investigated in a sample of 97 Australian women. In terms of the objective of predicting the severity of eating disturbance, the study explored the predictive utility of proneness to shame and guilt in a global sense, shame and guilt associated specifically with eating contexts, and shame associated with the body. The study also sought to determine if shame is a more prominent emotion than guilt among women who have eating difficulties. Shame associated with eating behavior was the strongest predictor of the severity of eating-disorder symptomatology. Other effective predictors were guilt associated with eating behavior and body shame. Eating disturbance was unrelated to proneness to shame and guilt in a global sense. Discussion of these findings focuses on the issue of determining whether self-conscious affects are best regarded as causes or as consequences of eating disturbance.

Shame and its psychopathologic correlates in two women's health problems: binge eating disorder and vulvodynia

Shame is thought to be a ubiquitous and destructive psychological process associated with psychiatric and medical conditions. This study examined its nature in two contrasting health problems that influence women's self-evaluations of their bodies and attractiveness, namely an eating disorder (a psychiatric disorder with medical implications) or vulvodynia (i.e., vulvar pain; a newly identified medical condition with psychiatric implications). A community sample of adult women without medical conditions served as an additional comparison group. Participants were 203 adult females: 72 with DSM-IV-defined Binge Eating Disorder (BED), 57 with vulvodynia, and 74 non-patient controls. The three study groups differed significantly: the BED group reported greater shame than the vulvodynia group, and the BED and vulvodynia groups reported greater shame than the control group. Higher levels of shame were associated with higher levels of symptomatic functioning within each group.

A descriptive analysis of factors contributing to binge eating

This study was designed to examine temporally proximal and remote antecedents as well as immediate and delayed consequences of binge eating behavior. Participants included 16 undergraduate females who reported engaging in binge eating at least two times per week and experiencing a sense of lack of control during binge eating episodes on the Questionnaire of Eating and Weight Patterns. Results indicated that the most frequent proximal antecedents to binge eating were negative emotions such as feeling depressed, angry, empty, hopeless, worried, or dissatisfied. The most frequent consequences of binge eating included relief from negative feelings and thoughts and decrease in hunger or craving. The results of this study suggest that the function of binge eating can be identified through assessment of antecedents and consequences with real time recording and retrospective reports. Treatment implications are discussed.

Family climates: family factors specific to disturbed eating and bulimia nervosa

More than a decade of research has characterized the families of individuals with bulimia and bulimia anorexia (Anorexia Nervosa, Binge/Purging Type) as less expressive, less cohesive, and experiencing more conflicts than normal control families. This two-part study investigated variables believed more directly related to disturbed eating and bulimia as contributing to a "family climate for eating disorders." In Study 1. a nonclinical sample of 324 women who had just left home for college and a sample of 121 mothers evaluated their families. Principal-components analyses revealed the same factor structure for both students and mothers, with Family Body Satisfaction, Family Social Appearance Orientation, and Family Achievement Emphasis loading together, representing the hypothesized family climate for eating disorders: the remaining variables loaded with the more traditional family process variables (conflict, cohesion, expressiveness), representing a more general family dysfunction. As predicted, the family climate for eating disorders factor score was a more powerful predictor of disturbed eating. Study 2 extended these findings into a clin ical population, examining whether the family climate for eating disorders variables would distinguish individuals with bulimia from both depressed and healthy controls. Groups of eating-disordered patients (n = 40) and depressed (n = 17) and healthy (n = 27) controls completed family measures. The eating-disordered group scored significantly higher on family climate variables than control groups. Family process variables distinguished clinical groups (depressed and eating disordered) from healthy controls, but not from one another. Controlling for depression removed group differences on family process variables, but family climate variables continued to distinguish the eating-disordered group from both control groups. Indications for further research are discussed.

Personality and affectivity characteristics associated with eating disorders: a comparison of eating disordered, weight-preoccupied, and normal samples

The purpose of this study was to assess the relative contribution of personality and emotional experience to self-reported eating attitudes in a group of patients with clinically diagnosed eating disorders, a weight-reduction training group (Weight Watchers), and a control group without body weight problems. Participants in this study (N = 114) completed Estonian versions of the Eating Disorder Inventory-2 (EDI-2; Garner, 1991), NEO Personality Inventory (Costa & McCrae, 1989), and Positive Affect and Negative Affect Schedule, Expanded Form (Watson & Clark, 1994). Data demonstrated validity of the Estonian version of EDI-2 in its ability to identify problems on a continuum of disordered eating behavior. Among the Big Five personality dimensions, Neuroticism made the largest contribution to EDI-2 subscales. Two other dimensions, Openness to Experience and Conscientiousness, also predispose individuals to eating problems. Personality traits made a larger contribution to the self-reported eating pathology than the self-rated effects experienced during the last few weeks. It was argued that personality dispositions have a larger relevancy in the etiology of eating disorders than emotional state.

Eating behavior of bulimics, self-identified binge eaters, and non-eating-disordered individuals: what differentiates these populations?

This article reviews and critiques the eating behavior literature comparing the binge and non-binge-eating episodes of three populations of normal-weight women: bulimics, self-identified binge eaters, and non-eating-disordered women. The specific behaviors evaluated are number of calories consumed during different types of eating episodes, frequency of binge eating, number of eating episodes, rate of food consumption, the macronutrient composition of the food ingested, and context and duration of eating. Differences in these populations' eating behavior are analyzed in terms of their theoretical contribution. It is concluded that differences in the observed behavior of these groups are consistent with restraint theory, purge opportunity, and the forbidden foods hypothesis. Conversely, results do not support carbohydrate craving theory or a deficit in the satiety mechanisms of bulimics. Suggestions for future research are presented.

Cognitive content specificity in selective attention across four domains of maladjustment

This research provided a rigorous examination of content-specific selective attention effects across the maladjustment domains of depression, anxiety, bulimia, and Type A behaviour. Study 1 utilized a self-referent endorsement task to obtain a set of empirically validated stimulus adjectives related to each maladjustment domain for use in the attentional paradigm in Study 2. Moreover, Study 1 provided some initial support for content-specificity proposals at the self-schema level Self-descriptive ratings in Study 1 indicated that depressed individuals uniquely identified themselves with adjectives relating to hopelessness, loss and failure. In contrast, the unique self-descriptive adjectives of anxious individuals centered on themes of social threat. Bulimics, in turn, endorsed unique self-descriptors relating to food and weight issues, whereas Type A self-descriptions were uniquely associated with achievement concerns. Content-specificity effects for selective attention were obtained in Study 2 for three of the four domains of interest (i.e. depression anxiety, and bulimia). Using a modified probe detection task, and very stringent criteria for group classification, it was found that individuals in each of these three groups selectively attended to personal adjectives that were hypothesized to be of specific relevance to their underlying cognitive concerns. Limited content-specificity effects were obtained for an incidental recognition measure, with only the depressed and bulimic groups showing enhanced memory performance for personal adjectives uniquely related to their dominant self-views. These findings are discussed in terms of various content-specificity distinctions across the four domains of maladjustment, including possible implications for the expression of differential behaviours for each domain.

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

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

Histories of childhood trauma and complex post-traumatic sequelae in women with eating disorders

The profound self-destructiveness and tenacity of eating disorders found among women abused and neglected in childhood become comprehensible when understood within a complex posttraumatic conceptualization as desperate attempts to regulate overwhelming affective states and construct a coherent sense of self and system of meaning. Trauma leads to the predictable consequences of dysregulation of the arousal system, avoidance, and constriction of affect; coherence of self and world are shattered. Abused patients' childhood experiences teach them that to need is to expose oneself to the pain of abandonment and betrayal at the hands of individuals responsible for their care. Consequently, needs-psychological, physical, and spiritual-come to be perceived as dangerous, and human relationships are simultaneously yearned for and feared. Robbed of the opportunity to develop a cohesive self and a coherent system of meaning and faith to sustain from within, the traumatized eating-disorder patient turns to the culture to tell her who to be and how to live; she learns that to conquer rather than satisfy needs and to be "in control" (an internal state of equanimity manifested externally in a thin body) will bring meaning and purpose. Binge eating, purging, and starving become apt metaphors for the boundless hunger, the wish to fulfill needs together with the wish to rid oneself forever of need, the desire to "purify" the damaged psychic and physical self, and the hope of restoring meaning. The treatment of the traumatized eating disorder patient is complex. Individual therapy provides the opportunity for intensive relational work that begins to restore faith in human connection and that provides a "safe base" from which to examine the trauma and separate past from present. Therapy groups for eating-disordered women and trauma survivors provide relief from isolation, valuable perspectives from others who have "been there," and the opportunity to contribute to others' healing as one heals. Ultimately, these patients must be willing to leave the world of obsession with food and weight, which guarantees safety from interpersonal hurt while it simultaneously guarantees that hope will not be restored. Though reconnecting with humanity carries the risk of further pain, it opens up the opportunity for connection, healing, and growth.

Emotions and cognitions associated with bingeing and weight control behavior in bulimia

The examination of cognitions and emotions during the bulimic cycle is critical in understanding possible maintenance factors involved in bulimia. In this study, 22 bulimics and 22 nonbulimics recorded their thoughts and feelings every 2 waking hours over a 6-day period. Bulimics additionally recorded their moods and thoughts during their binges and compensatory behaviors (e.g., purging, exercise). Higher levels of negative affect were reported at all stages of the cycle compared to baseline, although negative affect decreased after the compensatory behavior stage. Subjects also reported stronger distorted cognitions before and after the binge compared to baseline. One of the distorted cognitions (feeling fat) decreased in strength after subjects engaged in compensatory behavior. Additional analyses revealed that most levels of negative affect and distorted cognitions were elevated prior to binges as compared to meals. Finally, negative affect and distorted cognitions were stronger after binges than after meals.

The capacity to be alone as a stress buffer

The hypothesis that the ability to comfortably spend and use time alone is a buffer against effects of stress, comparable to social support, was tested. A 20-item instrument was developed to evaluate the capacity to be alone (Winnicott, 1958) and was then administered by telephone survey to 500 U.S. adults. Findings differed for two dimensions of the capacity to be alone. Reported comfort in being alone was found to be related to lower depression, fewer physical symptoms, and greater satisfaction with life. Reported ability to use time alone to deal with stress was not related to well-being. Neither dimension showed the expected interaction with stress, and individuals with high stress who reported high solitary coping exhibited greater vulnerability on one dimension of well-being, suggesting that this coping style may reflect maladjustment.

Nocturnal eating in binge eating disorder and matched-weight controls

OBJECTIVE

To examine the association of nocturnal eating (getting up out of bed to eat) with overweight, binge eating, and negative mood or anxiety.

METHOD

Forty overweight women diagnosed with binge eating disorder (BED) and 39 overweight controls monitored their nocturnal eating for an average of eight nights.

RESULTS

Seven instances of nocturnal eating were recorded by 6 patients, all of whom were binge eaters. Foods consumed nocturnally tended to be selected from those favored for binge episodes, and reported control over nocturnal eating was low. Patients reported tiredness, but not poor mood or anxiety, at the nocturnal eating episodes.

DISCUSSION

In this sample, nocturnal eating was associated more with eating disorder than overweight. This report should provide the basis of future work to determine whether nocturnal eating should be evaluated and treated among eating disordered or overweight groups of patients.

Interrupting the binge-purge cycle in bulimia: the use of planned binges

OBJECTIVE

To describe the rationale and use of a new procedure aimed at bringing binge/purge behavior directly under therapeutic control via the use of planned binges.

METHOD

Research investigating the specific effects of the various cognitive and behavioral components of the standard cognitive-behavioral treatment (CBT) approach for bulimia nervosa is examined in combination with comprehensive reviews of the treatment outcome literature.

RESULTS

These reviews suggest that while treatment has largely been effective at reducing binge-purge frequencies, it does not result in the elimination of the presenting problem for a significant proportion of participants. Evidence is presented to suggest that this may be accounted for by cognitive-behavioral approaches employing indirect procedures to bring the disordered patterns of eating under control. The application of the planned binge approach is illustrated by two cases treated at the University of New South Wales Post Graduate Psychology Clinic.

DISCUSSION

These cases in combination with the analysis of the potential deficits of the standard behavioral procedures employed in CBT provide tentative support for the use of planned binges as an addition to the strategies currently used in the treatment of binge and purge behavior. In conclusion the paper explores some of the ethical implications raised by asking subjects to engage in their problematic behavior.

Dissociation in bulimic and non-eating-disordered women

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

Alexithymia, depression, and treatment outcome in bulimia nervosa

Disturbances in emotional awareness, sometimes referred to as alexithymia, have been hypothesized to contribute to the development of binge/purge symptoms among women with bulimia nervosa (BN) and/or are considered secondary to the state of depression and/or disordered eating. The present study was designed to assess alexithymia among women with BN, to evaluate the interrelationship between alexithymia, depression, and somatic symptoms, and to determine whether an intensive group psychotherapy program contributes to a reduction in the degree of alexithymia. Thirty-one of 50 BN women (62%) who completed The Toronto Hospital Day Hospital Program for Eating Disorders (DHP) were administered pretreatment and posttreatment questionnaires. Findings from this clinical sample were compared with those from 20 non-eating-disordered women who completed the same battery. Using the Toronto Alexithymia Scale (TAS), significantly more BN women were alexithymic at pretreatment (61.3%) and post-treatment (32.3%) than in the comparison group (5.0%), even when depression was controlled for. At discharge, abstinence from binge/purge episodes was associated with a significant reduction in alexithymia, although there was a significant correlation between TAS scores, depression, and vomit frequency. Alexithymia among BN women is not simply a concomitant of disordered eating. Its partial reversibility following an intensive psychotherapy program may be a direct effect of the treatment and/or may be secondary to a reduction in depressive and/or binge/purge symptoms.