Binge Eating : Psychological Factors, Symptoms and Treatment [1 ed.] 9781617281464, 9781606922422

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Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009. ProQuest

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009. ProQuest

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.

BINGE EATING: PSYCHOLOGICAL FACTORS, SYMPTOMS AND TREATMENT

No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009. rendering legal, medical or any other professional services.

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

BINGE EATING: PSYCHOLOGICAL FACTORS, SYMPTOMS AND TREATMENT

NATALIE CHAMBERS

Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.

EDITOR

Nova Science Publishers, Inc. New York

Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

Copyright © 2009 by Nova Science Publishers, Inc.

All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER

The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material.

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Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Binge eating : psychological factors, symptoms and treatment / Natalie Chambers, editor. p. ; cm. ISBN H%RRN 1. Compulsive eating. I. Chambers, Natalie. [DNLM: 1. Bulimia--therapy. 2. Bulimia Nervosa--therapy. 3. Bulimia--psychology. 4. Bulimia Nervosa--psychology. 5. Cognitive Therapy--methods. WM 175 B6129 2009] RC552.C65B565 2009 616.85'26--dc22 2008039631

Published by Nova Science Publishers, Inc.  New York

Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

CONTENTS

Preface

vii

Short Communication A: On the Relationship between Dissociation and Binge Eating Matthew Fuller-Tyszkiewicz and Alexander J. Mussap Short Communication B: Binge Eating: What We Can Learn from Multi-Ethnic Community Samples Fary M. Cachelin and Pamela C. Regan

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Short Communication C: Characteristics of binge eating in bulimia nervosa and binge eating disorder Cortney S. Warren, Nancy C. Raymond, Susanne S. Lee, Lindsay H. Bartholome and Susan K. Raatz Short Communication D: Pretreatment Motivational Enhancement Therapy Reduces Drop-out Rate from Group Cognitive Behavioural Therapy for Bulimia Nervosa Outpatients: A Preliminary Study Michiko Nakazato, Masaomi Iyo, Hiroyuki Watanabe , Goro Fukami and Mihisa Fujisaki Chapter 1

The Acquired Preparedness Model of Risk for Binge Eating Disorder: Integrating Nonspecific and Specific Risk Processes Jessica L. Combs and Gregory T. Smith

Chapter 2

Causal and Maintenance Factors in Binge Eating Disorder Christopher N. Ochner, Allan Geliebter and Eva Conceição

Chapter 3

Binge Eating in Relation to Addiction: Evidence from an Animal Model of Sugar Addiction Nicole M. Avena, Pedro Rada, Miriam E. Bocarsly and Bartley G. Hoebel

Chapter 4

Hypothesized Pathways from Childhood Emotional Abuse to Binge Eating Sarah Fischer and Erin Hartzell

Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

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13

23

43

55 87

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vi Chapter 5

Contents Binge Eating Symptoms in Obese Children and Adolescents – Influence of Parents and Effect of Treatment Barbara Hatzlhoffer Lourenço, Fernanda Baeza Scagliusi, Thais Arthur and Sandra Mara Ferreira Villares

145

Chapter 6

Binge Eating in Children and Adolescents Andrea B. Goldschmidt and Denise E. Wilfley

165

Chapter 7

Psychological Treatment of Binge Eating Disorder in Adults Kelly R. Theim and Denise E. Wilfley

185

Chapter 8

Cognitive-Behavioral Therapy for Binge Eating Disorder Jennifer D. Slane and Kelly L. Klump

209

Chapter 9

Cognitive Behavioral Treatment for Overweight, Obesity and Binge Eating Associated to Antipsychotic Drugs Yasser Khazaal, Emmanuelle Fresard, Anne Chatton, Sophie Rabia, Ueli Kramer and Daniele Zullino

Chapter 10

How Do Emotions Govern the Binge Eating Decision? Blanca Roldán-Ortega, Sonia Rodríguez-Ruiz, Silvia Moreno, Gonzalo Morandé and M.Carmen Fernández

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Index

Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

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PREFACE Binge eating disorder (BED) is the most common eating disorder among men and women. This book centers on binge eating, which consists of episodes of uncontrollable overeating, followed by compensatory behavior (i.e., purging, fasting, heavy exercising). People who suffer from this disease often try to hide their binge-eating episodes from others, and often feel ashamed or depressed about their overeating. Many factors may contribute to binge-eating, such as dissociation, which may undermine an individual's body image, and impulsivity. This book focuses on such factors as well as the frequency with which such behaviors occur in multi-ethnic populations, and the differences in frequency rates as a function of gender and identity. The differences in binge eating and bulimia nervosa behaviors are also explained, as well as the theory that binging on some palatable foods, such as sugar, can result in addictive-like behavior. The association between emotional abuse in childhood and future binge eating episodes are explained as well as the prevalence of BE episodes in overweight or obese children or adolescents. The effectiveness of certain treatments for binge-eating are described, including cognitive behavioral therapy (CBT), motivational enhancement therapy (MET) and combined treatment. Short Communication A - Psychological dissociation is over-represented in individuals diagnosed with an eating disorder, particularly when that eating disorder includes symptoms of binge eating. This has been interpreted as evidence that dissociative processes predispose binge eating by facilitating an ‘escape from awareness’ of the appearance-threatening aspects of certain foods. In this chapter we review research consistent with this cognitive explanation, as well as for competing explanations that focus on the disinhibitory effects of dissociation on behaviour. The authors include in this review recent results from our own research suggesting that dissociation, particularly somatoform manifestations of dissociation, also contributes to binge eating by undermining an individual’s body image. Limitations of the research are discussed, as is the need for greater clarity concerning the construct of dissociation. The chapter concludes with a recommendation for future research into the influence of somatic symptoms of dissociation on body image. Short Communication B - The recognition that binge eating and purging behaviors may play an important role in the etiology of eating disorders has led to a growing interest in delineating their prevalence and correlates. Much of the research in this area has utilized White female samples to the relative exclusion of men and ethnic minority populations. This situation poses serious threats to generalizability for researchers interested in disordered

Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

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Natalie Chambers

eating, weight control, and other health-related behaviors. The authors suggest that the use of community-based, multi-ethnic samples of adult men and women provides an important means by which researchers can address this limitation and improve the generalizability of their empirical findings. The present chapter begins by presenting a brief definitional overview of binge eating disorder, bulimia nervosa, and related behaviors. Next, we present evidence about the frequency with which these behaviors occur in multi-ethnic community samples, focusing particularly on whether frequency rates differ as a function of gender and ethnicity. The authors then consider factors that predict treatment seeking and delivery in multi-ethnic community samples, and present general conclusions and directions for future research. Short Communication C - Bulimia nervosa (BN) and binge eating disorder (BED) are both eating disorders characterized by recurrent binge eating episodes. Although the operational definition of binge eating is essentially the same for BN and BED, understanding potential similarities and differences in binge eating behavior is critical to evaluate the nosological status of BED as a unique diagnosis and to inform treatment and prevention efforts. The overarching purpose of this paper is two-fold: 1) to provide a literature review of data comparing binge eating behavior in individuals with BN and BED; and, 2) to present data examining differences in preferred binge foods and binge eating-related symptoms in a group of women with BN and BED. The literature review revealed many similarities and some important differences between the disorders with regards to binge size, food preferences and macronutrient intake, temporal patterns of eating, and hedonics. Data comparing preferred binge foods and binge eating-related symptoms in women with BN (n = 9) and BED (n = 12) indicated that women with BED identify salty snacks and oil-based foods as preferred binge foods more frequently than women with BN. Additionally, women with BN reported feeling more “miserable or annoyed” following a binge eating episode than women with BED. As a whole, these results suggest that some aspects of binge eating appear similar in women with BN and BED whereas others do not. Short Communication D - Background: Despite lots of evidence indicating the effectiveness of cognitive behavioural therapy (CBT) for bulimia nervosa (BN), drop-out rates continue to be a problem. The aims of this study were (i) to evaluate the efficacy of motivational enhancement therapy (MET) combined group CBT program using measures of eating psychopathology, psychological and social functioning scores, (ii) to compare drop-out rates between the CBT only group and the MET combined group CBT. Methods: Forty-one BN outpatients participated in this study. The participants were divided into two group programs; twenty-five participants engaged in the CBT only group program- a weekly group for 10 weeks and sixteen participants engaged in the MET combined group CBT program - a pretreatment of 5 weeks MET followed by 10 weeks of group CBT. Participants completed the Eating Disorder Inventory-2 (EDI-2), the Bulimic Investigatory Test, Edinburgh (BITE), as measures of eating psychopathology, the Toronto Alexithymia Scale (TAS-20), as measures of the degree of alexithymia, the Rosenberg SelfEsteem Scale (RSES), as measures of self-esteem. The Global Assessment of Functioning (GAF) and the Clinical Global Impression of Disease Severity (CGI) were measured at the initial assessment and at the end of treatment. Results: Both of the group programs showed significant improvement in the scores of the BITE, the EDI-2 and social functioning of the GAF. The CGI showed 32% of the participants in the CBT only group were responders, and 43% of the MET combined CBT

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Preface

ix

responded to the treatment. The MET combined group CBT dramatically reduced drop-out rates (12.5%) compared with the CBT only group (36%). Conclusion: The MET combined group CBT programme proved to be useful in reducing drop-out rates in the first-step treatment for BN outpatients. Although this study was not controlled it could represent a promising step towards the development of a brief intervention which enhances the benefits of group CBT for BN patients. Chapter 1 - Risk for binge eating disorder (BED) involves both nonspecific factors (those increasing risk for multiple disorders) and specific factors (those unique to BED). The authors decompose the disorder by examining examples of both types of constructs. In particular, they argue that BED, bulimia nervosa, problem drinking, problem gambling, smoking, and risky sex are all caused, in part, by a disposition to engage in rash actions when experiencing intense emotions. This disposition is called urgency. They provide evidence that, among high urgency individuals, the particular expression of rash action (such as binge eating) is a function of learning events specific to the disorder. In this way, they present an etiologic model that integrates nonspecific and specific contributors to risk. They describe the risk model in detail, including its microgenetic, neurotransmitter, brain system, personality, and learning components. They also contrast BED with both bulimia nervosa and anorexia nervosa, by describing dimensions of dysfunction for the latter two disorders that are not present in BED. Their theory involves both differentiation (of BED from other eating disorders) and integration (between BED and other urgency-based disorders). Chapter 2 - This commentary will address the causal and maintenance factors of binge eating disorder (BED). As with most psychological disorders, genetic and environmental influences interact in the development and maintenance of BED, but it remains unclear how much each factor contributes. The diathesis-stress model is briefly discussed as a useful framework for conceptualizing the etiology of BED. Evidence for heritability, hormonal dysregulation, and differential brain activation will be presented in support of a biological predisposition. Individual differences in affect regulation and response to external stressors are then discussed as environmental triggers. Finally, the relationship between dietary restraint and negative affect, and its potential contribution to the maintenance of BED is discussed. Chapter 3 - Binge eating is most often thought of as a maladaptive behavior associated with bulimia nervosa. However, this behavior is also noted in patients with obesity, making it of interest to study within the context of the rapidly-spreading obesity epidemic. It has been suggested that some individuals may develop addictive-like behaviors when consuming palatable foods in a binge pattern, which can lead to overeating and subsequent weight gain. This chapter summarizes the findings of several animal models of binge eating, all of which provide unique insights into the behavioral and physiological bases of abnormal eating patterns. Next, the behavioral and neurochemical similarities between binge consumption of a sugar solution and addictive-behaviors, similar to those seen in cases of drug abuse, are reviewed. These behaviors can be categorized as 1) “bingeing,” or the intake of unusually large amounts of food in a discrete period of time, 2) opiate-like “withdrawal,” as indicated by signs of anxiety and somatic distress, and 3) “craving,” which is measured during sugar abstinence. Signs of both locomotor and consummatory “cross-sensitization” between sugar and drugs of abuse have also been found. Underlying these behaviors are alterations in dopamine, opioid and acetylcholine functions in the nucleus accumbens, a brain region that processes reward and motivation. Distinctions are made between bingeing on fats and sugars,

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Natalie Chambers

which have different effects on behavior and body weight. Drawing on clinical and preclinical findings from other laboratories as well as our own, the authors present the theory that bingeing on some palatable foods, sugar in particular, can result in addictive-like behavior. Chapter 4 - The purpose of this chapter is to describe specific, hypothesized paths mediating the effect of emotional abuse in childhood to future binge eating and associated symptoms. Previous research on child abuse and later outcomes has examined global experiences of abuse without distinguishing the differential effects of physical from sexual or emotional abuse. More recent studies indicate that these types of abuse may be associated with different types of adult pathology. These discussions have led to a need to delineate specific theoretical models describing how these experiences lead to eating disturbances. This chapter will first summarize what is known to date regarding the association of emotional abuse with later binge eating disorder and bulimia nervosa. We review three prevailing models of the development of binge eating behavior and discuss how the effects of emotional abuse may contribute to each model. Third, we describe several hypothesized pathways from childhood emotional abuse experiences to later eating disturbances, summarizing evidence that supports them. One hypothesized pathway is the interaction of levels of the personality trait negative urgency, the tendency to act impulsively in response to distress, with the experience of emotional abuse. The authors hypothesize that individual differences in urgency may increase vulnerability to binge eating and/or purging. When individuals experience a stressor such as emotional abuse and have high levels of this trait, they may be more likely to cope with abuse in maladaptive methods such as binge eating. An additional hypothesized pathway involves the mediating role of poor distress tolerance skills. Individuals raised in an invalidating environment, such as one in which they experience emotional or psychological abuse, may not learn appropriate methods to identify and label their own emotions. This in turn may lead to the use of poor emotion regulation strategies, which may result in binge eating. Suggestions for empirical methods for testing these hypotheses are outlined. Chapter 5 - Binge eating (BE) episodes are associated to overweight, inclusively in youngsters, and can be involved with weight gain especially among subjects seeking treatment for obesity. Parents can adopt a number of practices to restrain their children’s eating habits. Nevertheless, instead of preventing obesity, they often contribute to overweight and disordered eating behaviors. First, the authors aimed to investigate the association between the BE symptoms exhibited by children and adolescents who sought treatment for obesity, and the BMI and BE symptoms of these patients’ parents. Secondly, we investigated whether a multidisciplinary treatment for obesity reduced the BE scores of these children and adolescents. A group of 128 children and adolescents (aged 10.9 ± 1.3, BMI 29.4 ± 3.7 kg/m2, BMI z score 2.2 ± 0.3) completed the Binge Eating Scale (BES) at the first consultation of the treatment program. Patients were classified as binge eaters (score ≥ 18 points; moderate BE = 18-26 points, and severe BE ≥ 27 points) or non-binge eaters (score < 18 points). Of the 128 patients, 39.1% presented BE symptoms (32.1% moderate BE, 7.0% severe BE). We obtained BMI values from 110 mothers and 95 fathers. Out of 110 mothers (BMI 28.7 ± 5.9 kg/m2), 75.5% were overweight (39.1% pre-obese, 32.7% obese, 3.6% severely obese). Among 95 fathers (BMI 28.7 ± 4.0 kg/m2), 83.2% were overweight (53.7% pre-obese, 28.4% obese, 1.1% severely obese). There was no significant association of parent’s BMI and BE symptoms in patients.

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Preface

xi

The BES was administered to a subgroup of 32 patients’ caregivers, who were classified as binge eaters or non-binge eaters according to the same criteria applied to patients. Twentyfive (78.1%) caregivers were categorized as non-binge eaters while 7 (21.90%) caregivers presented BE symptoms (15.6% moderate BE, 6.3% severe BE). We found no significant difference when comparing caregivers’ BE scores to patients with and without BE symptoms. Another subgroup of 54 patients (aged 10.8 ± 1.3, BMI 30.1 ± 4.8 kg/m2, BMI z score 2.2 ± 0.3) were followed monthly for a six-month period by physicians, nutritionists, psychologists and physical educators. BES was administered at the first and last consultations of this treatment period using the same classification criteria described previously. We observed a significant reduction in patients’ BE scores after multidisciplinary intervention (first consultation: 15.4 ± 7.4 points, last consultation: 7.7 ± 7.6 points; p < 0.0001). At the beginning of treatment, non-binge eaters corresponded to 57.4% of patients, whereas after intervention, 90.7% fulfilled this condition. Initially, 33.3% and 9.3% of children presented moderate and severe BE, respectively. At the end of treatment, 5.6% presented moderate BE and 3.7% severe BE. No association between patients’ BE symptoms or obesity degree and BE symptoms among their parents was found. However, it is noteworthy that these parents demonstrated considerable levels of overweight and obesity, providing some evidence pointing to an obesogenic environment, which along with genetic factors, probably helps to propagate these conditions in children. Finally, our results also indicated that six months of multidisciplinary intervention can impact children’s scores on the BES, by contributing toward improved eating behavior. Chapter 6 - Binge and loss of control eating are among the most common disordered eating behaviors reported by children and adolescents. Given their associations with overweight and elevated eating-related and general psychopathology, binge and loss of control eating are clearly significant problems warranting empirical and clinical attention. The past several years have seen dramatic advances in research on the development and correlates of pediatric binge and loss of control eating, yet important work remains to be done. The purpose of this paper is to review the current state of the field as it concerns research on binge and loss of control eating n children and adolescents. Extant literature on the classification, measurement, prevalence, distribution, correlates, etiology, and treatment of binge and loss of control eating in youth will be reviewed and consolidated in order to make clinical recommendations for healthcare providers. The current literature suggests that early detection of binge and loss of control eating in youth should be a priority in order to provide appropriate intervention, thereby helping to slow the trajectory of weight gain and prevent or reduce associated long-term negative consequences. Future research is required to explicate developmental pathways, and to develop novel prevention and treatment interventions for youth exhibiting binge and loss of control eating patterns. Chapter 7 - Binge eating disorder (BED) is currently the most prevalent eating disorder in adults. Adults with BED exhibit higher rates of obesity and specific and general psychopathology than their non-eating disordered counterparts. Current research on the psychological treatment of BED in adults is reviewed, including the rationale behind and empirical support for behavioral weight loss treatment (BWLT) and specialist treatments for BED, such as cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), dialectical behavior therapy (DBT), and others potentially warranting further study. Substantial empirical evidence supports the use of CBT and IPT for BED. Less intensive

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Natalie Chambers

treatments include BWLT, which cannot currently be recommended as a first-line treatment for BED, and guided self-help CBT, which has shown efficacy, at least among individuals with low eating disorder psychopathology. Future research should focus on the effective dissemination of specialist treatments in routine clinical care, the inclusion of diverse participant samples in clinical trials, and investigation of moderators and mediators of treatment outcomes. Chapter 8 - Although currently still categorized under the umbrella of eating disorder not otherwise specified, binge eating disorder (BED) is the most common eating disorder among men and women (Hudson, Hiripi, Pope, & Kessler, 2007). More than half of individuals with BED are obese and many have comorbid psychopathology including major depressive disorder, anxiety disorders, and substance use disorders (Grucza, Przybeck, & Cloninger, 2007; Striegel-Moore et al., 2001). Despite the increased prevalence and high rates of comorbidity, treatment for BED is in its infancy and the treatment of choice has not been identified. This chapter reviews the effectiveness of cognitive-behavioral therapy for the treatment of BED. Findings indicate that both group and individual cognitive-behavioral therapy is effective in decreasing binge episodes, disordered eating pathology (e.g., dietary restraint), and general psychopathology (e.g., depression), but has not resulted in weight loss. Psychopharmacological and weight loss treatment combined with cognitive-behavioral therapy has resulted in similar decreases in binge episodes and psychopathology, but may have the added benefit of weight loss in obese BED patients. However, the long-term efficacy of these medications and weight loss treatments has not been determined. In sum, cognitivebehavioral therapy appears to be a promising treatment for the core behaviors associated with BED, but may not address health related issues (i.e., obesity) that frequently accompany the illness. Chapter 9 - Objectives: Overweight, obesity and binge eating disorder are commonly reported in persons with antipsychotic drugs (AP). A 24 weeks randomized controlled study [12-weeks cognitive and behavioral therapy (CBT) vs. brief nutritional education (BNE)] has concluded to the effectiveness of CBT. The aim of the present paper is to confirm the previous results on a larger sample of patients, to assess the impact of the interventions on other dimensions of eating and weight-related cognitions, as well as to assess potential clinical indicators of outcomes such as AP drug, concomitant treatment, psychiatric diagnoses, binge eating and the severity of cognitive distortions. Method: A controlled study (12-week CBT vs. BNE) was carried out on 99 patients treated with AP and who have gained significant weight following this treatment. Binge eating symptomatology, eating and weightrelated cognitions, as well as weight and Body Mass Index(BMI) were assessed before treatment, at 12 weeks and at 24 weeks. Results: The findings confirm the usefulness and the effectiveness of the proposed CBT program in treating binge symptomatology, cognitive distortions and obesity in patients treated with AP. Reduction of binge symptoms and maladapted cognitions appeared early, whereas the effect on weight appeared later during the follow-up observation. No differences on outcomes were found neither across pharmacotherapy characteristics, diagnostic categories, binge eating nor in severity of cognitive distortions. Conclusions: The proposed CBT treatment is useful for patients suffering from weight gain associated with AP treatments,even when a concomitant treatment with lithium or valproate is given. Chapter 10 - Background. Individuals suffering from bulimia nervosa (BN) experience recurrent binge eating episodes and often have a propensity for drug abuse and other risky

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Preface

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health behaviors. Given the high long-term social and personal costs inherent in these behaviors, researchers and clinicians often question why individuals with BN constantly engage in these behaviors. According to the somatic marker hypothesis (Bechara et al., 2005), one explanation might be the presence of an emotional processing deficit expressed as a difficulty to make appropriate decisions. Several studies have tested this hypothesis by assessing executive function in relation to decision making in patients with BN (Duchesne et al., 2004). However, there has been no investigation of impulsivity, the key factor determining whether a person will make binge-eating decisions, based on their emotions (Nederkoorn, Eijs & Jansen, 2004). The aim of the present study was to examine the relationship between impulsivity, emotion, and decision-making in women with BN in comparison to women with anorexia nervosa (AN; non-binge eating type) and controls. Method. Patients with BN (n=14), AN (n=22), and a healthy control group (n=20) carried out two tasks: the Iowa Gambling Task (IGT) and an affective version of the Go/No-Go task. The IGT emulates real-life decision-making by means of a card game that evaluates the capacity to balance immediate rewards with long-term negative consequences. The affective version of the Go/No-Go task is a measure of motor impulsivity. Participants also completed a set of questionnaires on cognitive impulsivity, mood state, anxiety, and food craving. Results. Patients with BN performed considerably worse in the IGT and Go/No-Go task than did patients with AN and control participants. Patients with BN showed greater cognitive impulsivity, a more negative mood state, and greater anxiety and food craving in comparison to anorexia nervosa and control groups. Patients with BN and AN also differed significantly on ratings of impulsivity. Discussion. The poor inhibitory control shown by patients with BN suggests that impulsivity may be a central and distinctive component of the disorder, mediating emotionguided decision-making and binge eating behavior.

Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

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In: Binge Eating: Psychological Factors… Editor: Natalie Chambers

ISBN: 978-1-60692-242-2 © 2009 Nova Science Publishers, Inc.

Short Communication A

ON THE RELATIONSHIP BETWEEN DISSOCIATION AND BINGE EATING Matthew Fuller-Tyszkiewicz and Alexander J. Mussap School of Psychology; Deakin University Melbourne, Australia

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ABSTRACT Psychological dissociation is over-represented in individuals diagnosed with an eating disorder, particularly when that eating disorder includes symptoms of binge eating. This has been interpreted as evidence that dissociative processes predispose binge eating by facilitating an ‘escape from awareness’ of the appearance-threatening aspects of certain foods. In this chapter we review research consistent with this cognitive explanation, as well as for competing explanations that focus on the disinhibitory effects of dissociation on behaviour. We include in this review recent results from our own research suggesting that dissociation, particularly somatoform manifestations of dissociation, also contributes to binge eating by undermining an individual’s body image. Limitations of the research are discussed, as is the need for greater clarity concerning the construct of dissociation. The chapter concludes with a recommendation for future research into the influence of somatic symptoms of dissociation on body image.

INTRODUCTION Binge eating is the uncontrolled consumption of a large quantity of food over a relatively short period of time (American Psychiatric Association; APA, 2000). In bulimia nervosa, this binge eating contradicts the stated aims of the individual (to lose weight through food restriction) and typically is followed by compensatory/purgative behaviours. Clinical observations and correlational studies suggest that individuals diagnosed with an eating disorder (Chandarana & Malla, 1989; Katz & Gleaves, 1996; McCallum, Lock, Kulla, Rorty

Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

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Matthew Fuller-Tyszkiewicz and Alexander J. Mussap

& Wetzel, 1992; Torem, 1986; 1990; Vanderlinden, Vandereycken, van Dyck & Vertommen, 1993), particularly those with bulimic symptoms (Beato, Cano & Belmonte, 2003; Demitrack, Putnam, Brewerton, Brandt & Gold, 1990; Everill, Waller & MacDonald, 1995; Goldner, Cockhill, Bakan & Birmingham, 1991; Groth-Marnat & Michel, 2000; McManus, 1995; Waller et al., 2003), are more likely to exhibit symptoms of dissociation, such as depersonalization, derealization and absorption. In this chapter we attempt to elucidate the psychological processes underlying binge eating, particularly in the context of bulimia nervosa, by examining the relationship between binge eating and psychological dissociation. Two explanations of this relationship are considered. In the escape from awareness explanation, binge eating is an indirect result of dissociative cognitive strategies in response to appearance-threatening food stimuli (e.g., Everill & Waller, 1995). In the somatic explanation, one that has received far less empirical attention, binge eating is an indirect result of disturbed body self-awareness.

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DISSOCIATION AND ESCAPE FROM AWARENESS Dissociative disorders are characterized by deficits of consciousness, memory, and identity (APA, 2000), and are implicated in diminished behavioural self control and disturbances of self-awareness (Brown, 2002). These symptoms are particularly prevalent in individuals who have experienced trauma such as that associated with emotional, sexual or physical abuse, exposure to combat, witnessing the death of a loved one, etc. (e.g., Kihlstrom, Tataryn & Hoyt, 1993; Putnam et al., 1986; Schachter, Wang, Tulving & Freedman, 1982). The importance of trauma to the development of dissociation has been taken to suggest that dissociation may arise as a useful psychological defense mechanism that facilitates the escape from awareness of threatening scenarios (Everill & Waller, 1995; Hallings-Pott, Waller, Watson & Scragg, 2005; van der Kolk & van der Hart, 1989). According to traumatogenic explanations of dissociation, in certain individuals the dissociative response may generalize to and/or persist beyond the original traumatic scenario (Braun & Sachs, 1985). In these circumstances the dissociative response may be inappropriate and contribute to diminished self-awareness and self-control and undermine the development and use of responses more suited to the new scenario (Braun & Sachs). Heatherton and Baumeister (1991) propose that some individuals attempt to deal with negative cognitions and emotions by focussing their attention to stimuli in the present and immediate (and presumably innocuous) environment. Central to this escape from awareness process is the principle that each stimulus (e.g., object, action, event, etc.) has multiple levels of meaning: lower levels of awareness emphasize the concrete aspects of the immediate stimulus environment, whereas higher levels emphasize stimulus meaning and stimulus corelationships. Because high levels of awareness often involve consideration of societal norms and expectations, and stimulus consequences, it is thought that engagement in this level of awareness is necessary for maintaining behavioural control, including control over eating (Everill & Waller, 1995; Heatherton & Baumeister, 1991). There is evidence to suggest that eating behaviours can also be influenced by escape from awareness processes. For example, binge eaters typically report experiencing negative affect and/or engage in negative or disturbed self evaluations immediately prior to a binge episode

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(Cooper et al., 1988; Davis, Freeman & Garner, 1988; Lingswiler, Crowther & Stephen, 1989; Mitchell, Hatsukami, Eckert & Pyle, 1985; Powell & Thelen, 1996; Steiger et al., 1999; Tachi, Murakami, Murotsu & Washizuka, 2001). They are also more likely to use cognitive avoidance strategies when dealing with stressors in general (Troop, Holbrey, Trowler & Treasure, 1994).

The Disinhibition of Eating Fuller-Tyszkiewicz and Mussap (2008a) administered a survey to determine the extent to which four factors relevant to behavioural disinhibition serve as control-specific mediators of the relationship between dissociation and binge eating. Only impulsive urgency was identified as a significant mediator. Impulsive urgency is generally associated with giving in to temptations during heightened negative emotions (Whiteside & Lynam, 2001; Whiteside et al., 2005), and its mediating role is consistent with traumatogenic explanations of dissociation in which heightened negative emotions and cognitions activate dissociative processes (Nijenhuis, Spinhoven, van Dyck, van der Hart & Vanderlinden, 1998). The irrelevance of the remaining three factors (premeditation, perseverance and sensation-seeking) is consistent with the escape from awareness model, and also with recent neurophysiological evidence that dissociation does not undermine tasks requiring planning or strategy use (Bruce, Ray, Bruce, Arnett & Carlson, 2007; Cromer, Stevens, De Prince & Pears, 2006; Giesbrecht, Merckelbach, Geraerts & Sweets, 2004).

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The Processing of Threat Stimuli Several experimental investigations have been conducted into the cognitive processes underlying these behavioural disinhibition effects. Most dramatically, presentation of threat stimuli, such as the word ‘lonely’, has been shown to elicit increased food consumption in individuals, particularly individuals with pre-existing symptoms of disordered eating (Meyer & Waller, 1999; Waller & Mijatovich, 1998). Other experiments have sought to measure the cognitive suppression of information that has negative or threatening associations. In a modified version of the Stroop Interference task, participants were asked to identify the colour of a printed word. Reaction times for making correct colour identifications were generally found to be longer (slower) when the words were negatively valenced, particularly when the participants exhibited symptoms of an eating disorder (Meyer, Waller & Watson, 2000; Waller, Quinton & Watson, 1995; Waller, Watkins, Shuck & McManus, 1996) or who had been diagnosed with an eating disorder (Meyer et al., 2005; Mountford, Waller, Watson & Scragg, 2004). Of course, in order for a threatening stimulus to be suppressed it first must be processed at least to the extent that it can be recognized as a threat. For this reason, escape from awareness has been described as a two-stage process in which an initial hypervigilance designed to facilitate identification of threats is followed by attentional shifts away from the identified threat in order to minimize stress (Waller, Quinton, & Watson, 1995). Given this, it is unclear whether the reaction time data reported above reflect increased attention to the threat stimuli (and, hence, difficulty disengaging from this in order to complete the task) or

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cognitive disengagement from the task (and hence evidence of the cognitive avoidance hypothesized). In this context it is interesting to note that researchers have shown a link between threat presentation and subsequent dissociative experiences in eating disordered individuals (Hallings-Pott et al., 2005), suggesting that even short-term presentation of these threat stimuli (e.g., the word ‘lonely’) may be sufficient to prompt a cognitive avoidance-type response, as evidenced by increased state dissociation, in particular, feelings of derealization.

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Food as a Threat to Appearance Despite the centrality of food and appearance concerns in individuals diagnosed with an eating disorder (APA, 2000), extant research suggests that food and appearance-threatening stimuli do not necessarily elicit cognitive-avoidance responses. For example, Waller and colleagues report that subliminal presentation of a food cue (the word ‘hungry’) does not reliably undermine completion of a subsequent word search task (Mountford et al., 2004), nor does it increase subsequent food consumption relative to a neutral cue condition (Meyer & Waller, 1999). Furthermore, participants are neither slower nor faster at solving anagrams when the words considered are food items (e.g., ‘beef’, ‘lamb’, ‘rice’, etc.) rather than nonfood items (Meyer et al., 2005). However, Fuller-Tyszkiewicz and Mussap (submitted 2008b) have criticized these studies for using food words that are not necessarily threatening (many may, in fact, be viewed as positive words by individuals who are not concerned with their appearance) and that the words are at best only symbolic representations of threats rather than actual threats. On these bases Fuller-Tyszkiewicz and Mussap measured reaction times for processing of food and appearance words (both positive and negative) immediately prior to and following actual presentation of a tray containing tempting but appearance-threatening food items (pastries). The relationships between dissociation and reaction times for processing the foodand appearance-related words were in large part as predicted by the escape from awareness model: As expected, level of dissociation correlated positively with reaction times for processing appearance threats (e.g., ‘fat’, ‘ugly’, etc.). Furthermore, dissociation was unrelated to reaction times for processing positive aspects of food (e.g., ‘delicious’, ‘sweet’, etc.) and for processing information related to compensatory behaviours following overeating (e.g., ‘purge’, ‘exercise’, etc.). This is consistent with the notion that dissociative processes operate in response to threatening rather than positive stimuli. However, in contradiction of the escape from awareness model, the effects associated with appearance threats were not magnified in individuals with self-reported concerns with appearance or with food. Collectively, the results of the abovementioned studies are consistent with the proposition that individuals with body image concerns, symptoms of disordered eating, and/or a diagnosed eating disorder, process threat stimuli differently from non-eating-disordered individuals. Surprisingly, the threats in question are not necessarily related to food or appearance but can include negative information of a general nature.

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DISSOCIATION AND DISTURBED BODY IMAGE Research into dissociation in the context of binge eating typically has focussed on cognitive and behavioural factors of the type described in the previous sections. However, dissociation is understood to include non-cognitive symptoms (Brown, 2002; Cardeña, 1994; Holmes et al., 2005). In the following section on the somatic effects of dissociation, the influence of dissociation on binge eating will be considered in terms of its effects on perceptual body image.

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Perceptual Body Image and Disordered Eating Waller and colleagues (2003) observed that somatoform dissociation, that is, bodily symptoms of dissociation, predict variance in disordered eating symptomatology additional to that predicted by generalized, psychoform symptoms (Waller et al., 2003). This observation has been replicated by Fuller-Tyszkiewicz and Mussap (2008a), who also noted that the effect is most pronounced for binge eating symptoms of disordered eating. Somatic symptoms of dissociation include disruptions to bodily functions and disturbances of body perception, such as altered, inaccurate, or poorly-integrated body selfidentity. Interestingly, disturbances of body perception are also thought to be relevant to eating disorders (e.g., Bruch, 1962). In addition to over-valuing their appearance (KjaerbyeThygesen, Munk, Ottesen & Kjaer, 2004), individuals diagnosed with an eating disorder are also more likely to over-estimate their physical body size (Fitzgibbon et al., 2003; Polivy & Herman, 2002; Stice, Killen, Hayward & Taylor, 1998), report fluctuations in their selfestimated body size over time (Brinded, Bushnell, McKenzie & Wells, 1990; Rudiger, Cash, Roehrig & Thompson, 2007), and possess a body image that is more malleable in terms of its size (Mussap & Salton, 2006), particularly following exposure to images of thin-idealized bodies (Irving, 1990) and during scrutiny of their appearance by others (Cash & Fleming, 2002). Typically, these body image disturbances have been interpreted as evidence of cognitiveaffective disturbances (Gardner & Bokenkamp, 1996). However, there is also evidence that disturbed perceptions may also be responsible. For example, there is neurophysiological evidence that individuals diagnosed with an eating disorder exhibit abnormal functioning in right parietal regions of the cerebral cortex that are thought to integrate perceptual information relevant to body image (Grunwald, Ettrich, Busse, Assmann, Dähne, & Gertz, 2002; Råstam, Bjure, Vestergren, Uvebrant, Gillberg, Wentz, & Gillberg, 2001; Smeets & Kosslyn, 2001). Psychological evidence has also revealed associations between eating disorder symptomatology and malleability of perceptual body image. Using what is referred to as the ‘rubber hand illusion’, Mussap and Salton (2006) observed that individuals with symptoms of disordered eating are more likely to subjectively incorporate a prosthetic hand into their body image. Interestingly, and consistent with the involvement of right-brain regions such as the postcentral gyrus and neighbouring areas within the contralateral right parietal cortex (Lloyd, Shore, Spence & Calvert, 2002), the relationship between the rubberhand illusion and disordered eating symptomatology was only obtained when the left hand was tested.

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Dissociation and Body Image Disturbance On the basis of the rubber-hand illusion results, Mussap and Salton (2006) proposed that the body image disturbances reported by individuals diagnosed with an eating disorder reflect an underlying instability of perceptual body image. Furthermore, because dissociation has been found to correlate positively with body-evaluative aspects of disordered eating, such as body dissatisfaction, internalization of the thin ideal and the tendency to compare one’s body with that of others (Beato, Cano & Belmonte, 2003; Fuller-Tyszkiewicz & Mussap, 2008a), Mussap and Salton proposed that dissociation may undermine normal integration of appearance-relevant information and, in turn, contribute to body image vulnerability to the thin ideal. Fuller-Tyszkiewicz and Mussap (submitted 2008c) tested this idea by experimentally evaluating the body image of a convenience sample of 93 female university students, and tested various dimensions of body image disturbance as possible mediators of the relationship between somatoform dissociation and binge eating. In this study, body image was measured by presenting participants with photographs of their own bodies digitally altered to produce progressively thinner and wider versions. The photographs were presented randomly according to the psychophysical method of constant stimuli and participants were asked to determine whether each image presented to them was thinner or wider than their actual body size. This method yielded three independent measures of body image disturbance: systematic errors in body size judgments (body image distortion), reduced sensitivity to body size differences (body image uncertainty), and variability in body size judgments over time (body image instability). Although somatic symptoms of dissociation were unrelated to body image distortion or uncertainty, a significant positive relationship was observed between dissociation and body image instability. Binge eating yielded a similar pattern of results, being significantly related to body image instability but unrelated to body image distortion or uncertainty. Most importantly, path analyses revealed that the relationship between somatic symptoms of dissociation and binge eating was significantly mediated by body image instability. Fuller-Tyszkiewicz and Mussap (submitted 2008c) speculated that body image instability serves to make individuals vulnerable to external standards of appearance (i.e., the thin ideal) and, in turn, makes them susceptible to disordered eating, including binge eating. They tested this idea by exposing their participants to a series of images of thin female models sourced from the internet, and measuring the extent to which their body image estimates were altered following this exposure. However, body image malleability, measured in this way, was found to be unrelated either to binge eating or somatic symptoms of dissociation.

CONCLUSION This review of the literature critically examined the limited research that exists on the nature of the relationship between dissociation and binge eating. In reviewing this literature it became apparent that perhaps the greatest obstacle in clarifying this relationship is the construct of dissociation itself. More precisely, as a subjectively-defined, multi-dimensional construct (Brown, 2002; Holmes et al., 2005), dissociation may influence an individual’s

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relationship with food through its effects on cognitions and emotions associated with particular types of food, diminished behavioural self-control in the context of food and eating, and even disturbances of body self-perception. Consistent with this view, the extant literature suggests that the relationship between dissociation and binge eating may reflect underlying disturbances in the processing of threat information and/or the processing of body-image information. Specifically, evidence was reviewed indicating (i) that dissociation is related to cognitive suppression of threat stimuli, including appearance threats, (ii) that dissociation is related to body image instability, and (iii) that both cognitive suppression of appearance threats and body image instability are in turn related to binge eating. Although these are promising results, they represent only a limited form of evidence, partly because it remains unclear (and untested) exactly how suppression of appearance threats and unstable body image contribute to binge eating, and partly because most of the relevant research has been conducted with convenience samples which did not include individuals diagnosed with either dissociation or disordered eating. Furthermore, it is important to note that the body image results reviewed were sourced from a very limited number of studies (certainly in comparison to the number of studies that have explored cognitive factors). The lack of body perception research in the area is particularly surprising given the prevalence and salience of somatic symptoms in dissociation, and the obvious relevance of body image in disordered eating. We suggest that these results warrant further empirical attention, particularly into the somatic bases of the relationship between dissociation and binge eating.

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ACKNOWLEDGEMENTS This review paper was supported by a grant from the Australian Research Council (DP0556370)

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van der Kolk, B.A., & van der Hart, O. (1989). Pierre Janet and the breakdown of adaptation in psychological trauma. American Journal of Psychiatry, 146, 1530-1540. Vanderlinden, J., Vandereycken, W., van Dyck, R., & Vertommen, H. (1993). Dissociative experiences and trauma in eating disorders. International Journal of Eating Disorders, 13(2), 187-193. Waller, G., Babbs, M., Milligan, R., Meyer, C., Ohanian, V., & Leung, N. (2003). Anger and core beliefs in the eating disorders. International Journal of Eating Disorders, 34(1), 118-124. Waller, G., & Mijatovich, S. (1998). Preconscious processing of threat cues: Impact on eating among women with unhealthy eating attitudes. International Journal of Eating Disorders, 24, 83-89. Waller, G., Quinton, S., & Watson, D. (1995). Processing of threat-related information by women with bulimic eating attitudes. International Journal of Eating Disorders, 18, 189193. Waller, G., Watkins, H., Shuck, V. & McManus, F. (1996). Bulimic psychopathology and attentional biases to ego threats among non-eating-disordered women. International Journal of Eating Disorders, 20, 169-176. Whiteside, S.P., & Lynam, D.R. (2001). The five factor model and impulsivity: Using a structural model of personality to understand impulsivity. Personality and Individual Differences, 30(4), 669-689. Whiteside S.P., Lynam, D.R., Miller, J.D., & Reynolds, S.K. (2005). Validation of the UPPS impulsivity behaviour scale: A four-factor model of impulsivity. European Journal of Personality, 19, 559-574.

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In: Binge Eating: Psychological Factors… Editor: Natalie Chambers

ISBN: 978-1-60692-242-2 © 2009 Nova Science Publishers, Inc.

Short Communication B

BINGE EATING: WHAT WE CAN LEARN FROM MULTI-ETHNIC COMMUNITY SAMPLES Fary M. Cachelin* and Pamela C. Regan Department of Psychology California State University, Los Angeles, CA

ABSTRACT

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The recognition that binge eating and purging behaviors may play an important role in the etiology of eating disorders has led to a growing interest in delineating their prevalence and correlates. Much of the research in this area has utilized White female samples to the relative exclusion of men and ethnic minority populations. This situation poses serious threats to generalizability for researchers interested in disordered eating, weight control, and other health-related behaviors. We suggest that the use of community-based, multi-ethnic samples of adult men and women provides an important means by which researchers can address this limitation and improve the generalizability of their empirical findings. The present chapter begins by presenting a brief definitional overview of binge eating disorder, bulimia nervosa, and related behaviors. Next, we present evidence about the frequency with which these behaviors occur in multi-ethnic community samples, focusing particularly on whether frequency rates differ as a function of gender and ethnicity. We then consider factors that predict treatment seeking and delivery in multi-ethnic community samples, and present general conclusions and directions for future research.

*

Address correspondence to: Fary M. Cachelin, Ph.D., Department of Psychology, California State University at Los Angeles, 5151 State University Drive, Los Angeles, CA 90032-8227. E-mail: [email protected]

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Fary M. Cachelin and Pamela C. Regan

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INTRODUCTION Eating disorders are associated with a host of adverse physical, psychological, and social outcomes; for this reason, they are widely considered to be among the most pernicious of clinical syndromes (Becker, Grinspoon, Klibanski, & Herzog, 1999). Epidemiological research suggests that prevalence rates of anorexia nervosa and bulimia nervosa have increased over time (Hoek & van Hoeken, 2003) and, consequently, social and behavioral scientists increasingly have focused their attention on identifying risk factors for these eating disorders. Binge eating and purging behaviors (e.g., self-induced vomiting, excessive use of laxatives) appear to constitute one such category of risk factor (Mora-Giral, Raich-Escursell, Segues, Torras-Clarasó, & Huon, 2004; Striegel-Moore & Cachelin, 2001). The recognition that binge eating and purging behaviors may play an important role in the etiology of eating disorders has led to a growing interest in delineating their prevalence and correlates (French, Story, Downes, Resnick, & Blum, 1995; Neumark-Sztainer, Story, Falkner, Beuhring, & Resnick, 1999). Much of the research in this area has utilized White female samples to the relative exclusion of men and ethnic minority populations. This may be a reflection of the fact that higher rates of eating disorders historically have been found among female than among male populations, and among White populations than among other ethnic groups (see Hoek & van Hoeken, 2003; Striegel-Moore et al., 2003). Nonetheless, this situation poses serious threats to generalizability for researchers interested in disordered eating, weight control, and other health-related behaviors (Franko & Striegel-Moore, 2002; Marcus & Kalarchian, 2003). As we have suggested previously (see Cachelin & Regan, 2006; Regan & Cachelin, 2006), the use of community-based, multi-ethnic samples of adult men and women provides an important means by which researchers can address this limitation and improve the generalizability of their empirical findings. The present chapter begins by presenting a brief definitional overview of binge eating and related disorders and their clinical significance. Next, we present evidence about the frequency with which these behaviors occur in multiethnic community samples, focusing particularly on whether frequency rates differ as a function of gender and ethnicity. We then consider factors that predict treatment seeking and delivery in multi-ethnic community samples, and present general conclusions and directions for future research.

DEFINITION AND CLINICAL SIGNIFICANCE The key components of “binge eating” are the consumption of a large amount of food that is accompanied by a sense of loss of control. The American Psychiatric Association (2000) defines an episode of binge eating as being characterized by the presence of both of the following criteria: 1) eating, in a discrete period of time (e.g., within a two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances, and 2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) (p. 594). Additional characteristics of binge eating include feelings of disgust during

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Binge Eating: What We Can Learn from Multi-Ethnic Community Samples

15

the binge episode, eating rapidly, experiencing agitation or a sense of compulsion to eat, altered consciousness or dissociation during eating, and secretiveness related to feelings of shame (Fairburn, 1995). The eating disorders that include binge eating as a key criterion, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSMIV-TR; American Psychiatric Association, 2000), are Bulimia Nervosa (BN), Binge Eating Disorder (BED), and subsyndromal BN. Both BED and subsyndromal BN are subtypes of Eating Disorder Not Otherwise Specified (EDNOS), which is a diagnostic category in the DSM-IV that includes eating disorders other than BN and anorexia nervosa (AN). Bulimia Nervosa (BN) is characterized by recurrent binge eating, body image disturbance, and the recurrent use of inappropriate compensatory behaviors (American Psychiatric Association, 2000). Research has shown that BN is associated with considerable psychiatric comorbidity, diminished psychosocial adjustment, and physical conditions such as electrolyte imbalance, bone mass loss, and infertility (Agras, 2001). When untreated, BN often takes a cyclical or chronic course in many individuals (Sullivan, 2002). Subsyndromal BN (EDNOS) is a clinical syndrome in which binge eating does not reach the frequency threshold required for a diagnosis of BN (i.e., a minimum average frequency of twice per week over the previous three months). Subsyndromal BN, as defined in three large epidemiological studies, is recurrent binge eating at a minimum average frequency of once per week over the previous three months, and clinically significant impairment due to the eating problem (Garfinkel et al., 1995; Kendler et al., 1991; Lewinsohn, Striegel-Moore, & Seeley, 2000). These studies have shown that at least as many individuals have subsyndromal BN as full syndrome BN, and that individuals with the two disorders are similar in quality of symptomatology and pathology (Garfinkel et al., 1995; Kendler et al., 1991; Lewinsohn et al., 2000). It has been argued that the frequency criterion for binge eating in BN (i.e., two times per week) is an arbitrary threshold that excludes from diagnosis individuals who have clinically significant disorders (Garfinkel et al., 1995). Moreover, longitudinal research indicates that few individuals with subsyndromal BN recover and almost 50% go on to develop full syndrome BN or AN (Herzog, Hopkins, & Burns, 1993). Binge Eating Disorder (EDNOS: BED) is defined by recurrent binge eating in the absence of inappropriate compensatory behaviors that are required for the diagnosis of BN. Additional criteria include the presence of at least three of five behavioral indicators of loss of control over binge eating (e.g., eating when not hungry; eating in secret), as well as distress over the binge eating behavior (American Psychiatric Association, 2000). As with BN, BED is associated with considerable medical and psychiatric comorbidity (Grilo, Masheb, & Wilson, 2005; Wilfley et al., 2000). Furthermore, obesity – which has been shown to contribute to the leading causes of death in the U. S., including hypertension, cardiovascular disease, and Type II diabetes – is a major medical complication in BED (National Task Force on the Prevention and Treatment of Obesity, 2000). In sum, BN, subsyndromal BN and BED are associated with psychosocial impairment and considerable psychiatric and medical comorbidity including obesity. Research reviewed below demonstrates that these eating disorders, historically believed to be disorders of European and European American women (Smolak & Striegel-Moore, 2001), are prevalent among women and men of ethnic minority groups.

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Fary M. Cachelin and Pamela C. Regan

PREVALENCE Research conducted with multi-ethnic community samples reveals that rates of binge eating clearly differ as a function of participant gender and ethnicity. For example, in one recent investigation (Regan & Cachelin, 2006), we administered a questionnaire to a large sample (N = 1,225) of Latino, Asian, Black/African American, and White/European American women and men. Several of the items included in our questionnaire were based on the diagnostic criteria for eating disorders (American Psychiatric Association, 2000) and had been used previously in the self-report questionnaire developed for the 1996 National Eating Disorders Screening Program (Becker, Franko, Speck, & Herzog, 2003). One of these questions asked specifically about binge eating: “Have you gone on eating binges where you feel that you may not be able to stop? (Eating much more than most people would under the same circumstances).” Table 1. Frequency of Binge Eating as a Function of Participant Gender and Ethnicity

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Gender Ethnic Group Latino/a Total N No. reporting

Women

Men

366 58

165 18

% reporting Asian

15.8

10.9

Total N No. reporting

200 40

100 13

% reporting Black/African American

20.0

13.0

Total N No. reporting

127 25

71 4

% reporting White/European American

19.7*

5.6*

Total N No. reporting

112 23 20.5*

84

Total N No. reporting

805 146

420 43

% reporting

18.1*

10.2

% reporting Total

8 9.5*

Note: Within each row, percentages that share an asterisk (*) are significantly different. Z and p values are given in the text.

Table 1 presents the percentages of men and women from each ethnic group who responded affirmatively to this question (that is, the proportion who reported engaging in binge eating). Binge eating was equally common across the four ethnic groups – no significant differences were found among the Asian (17.7%), Latino (14.3%), Black/African American (14.6%), and White/European American (15.8%) sub-samples with respect to overall rates of this particular disordered eating behavior. There was a significant gender difference, however, such that more women (18.1%) than men (10.2%) reported having experienced episodes of binge eating (z = 3.63, p < .001). This finding was unexpected, as

Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

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other researchers employing community surveys generally have not found gender differences (Garfinkel et al., 1995; Hay, 1998). The most important result was the finding that the gender difference observed among our participants in frequency of binge eating was moderated by their ethnicity. Specifically, Asian men and women did not differ in their self-reported experience with binge eating. Neither did Latino men and women. However, a significantly greater proportion of Black/African American women than men had engaged in binge eating (19.7 vs. 5.6%, z = 2.68, p < .005). Similarly, more White/European American women than men reported having experienced episodes of binge eating (20.5 vs. 9.5%, z = 1.99, p < .05). The fact that frequency rates differed as a function of both gender and ethnicity underscores the importance of considering each of these group variables when examining binge eating and other eating disorder-related behaviors.

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FACTORS THAT PREDICT TREATMENT SEEKING AND DELIVERY Researchers and clinicians have suggested that eating disorders often go undetected and untreated, particularly among ethnic minority populations. This may be especially true with respect to individuals with BED or BN because, unlike those with AN, they tend to have a normal to above-average body mass index (BMI) and thus frequently present a “healthy” appearance to observers who might otherwise intervene (see Striegel-Moore et al., 2003). Given the debilitating and chronic nature of eating disorders, knowledge of the factors that impede or facilitate treatment seeking among these populations is clearly needed. In one recent study, we sought to identify some of these factors in a community sample of European American (EA) and Mexican American (MA) women with BED or BN. [Results for the total sample and all eating disordered groups are reported in Cachelin, Striegel-Moore, and Regan (2006).] We first examined whether the likelihood that our participants would seek professional treatment for their eating disorder was associated with their ethnicity. Our results indicated that it was. Specifically, while approximately half of our total participant sample reported having sought treatment (49.1%), a significantly greater percentage of EA women (65.1%) than MA women (30.7%) had sought some form of professional intervention and treatment for their disordered eating behavior (χ2 = 19.02, p < .001). A logistic regression analysis confirmed these results. Being EA increased the probability of seeking treatment by a multiplicative factor of 4.22 (z = 18.20, p < .001); that is, a woman was more than four times more likely to have sought treatment if she were EA than if she were MA. In an effort to understand the origins of this differential likelihood of treatment seeking, we compared the two groups of women on a number of variables, including: (1) current BMI, (2) frequency of binge eating, (3) level of distress regarding eating (6-point scale ranging from 1 = no distress to 6 = high distress), (4) duration of the eating disorder (current age minus onset age), (5) current level of depression (assessed with the Center for Epidemiologic Studies Depression Scale [CES-D; Radloff, 1977), and (6) number of lifetime psychiatric comorbidities (determined by scores on the Structured Clinical Interview for DSM-IV-TR [SCID-IV-TR; First, Spitzer, Gibbon, & Williams, 2001]). Our results indicated three differences. Specifically, MA women exhibited a higher average BMI, reported significantly less distress regarding their eating behavior, and had engaged in binge eating for a shorter

Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

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Fary M. Cachelin and Pamela C. Regan

period of time than EA women (all ps < .05). Thus, the lower rate of treatment seeking among our ethnic minority participants may reflect, in part, the fact that their distress about eating (and the duration of their binge eating behavior) may not yet have reached levels that lead them to conclude that they have a “problem” that requires clinical intervention. Surprisingly, among the sub-sample of eating disordered participants who had sought treatment (n = 79), only about half had been accurately diagnosed with an eating disorder (49.4%) and had been prescribed appropriate treatment (54.2%). As was the case with treatment seeking, the likelihood of eating disorder detection and actual treatment was strongly associated with ethnicity. A significantly greater proportion of EA women (67.2%) than MA women (24.0%) had received intervention for their eating disorder (χ2 = 13.16, p < .001). A logistic regression analysis indicated that being EA increased the probability of receiving treatment by a multiplicative factor of 6.50 (z = 11.77, p < .001); that is, a woman was almost seven times more likely to have had disordered eating detected and treated if she were EA than if she were MA. In sum, the majority of our sample of women with binge eating related disorders, and in particular those who were MA, had not received any intervention for the eating disorder or had received treatment that was inappropriate (e.g., being prescribed diet pills). Even when these women reached out for help and actively sought treatment, the opportunity to detect and treat these clinically significant problems was often missed by those providers from whom they sought assistance.

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CONCLUSIONS AND FUTURE RESEARCH DIRECTIONS Our research has demonstrated that eating disorders, particularly those accompanied by binge eating such as Binge Eating Disorder (BED) and Bulimia Nervosa (BN), do occur among ethnic minority populations and pose serious mental and physical health risks (Cachelin et al., 2000, 2005, 2006; Regan & Cachelin, 2006). Eating disorders are chronic and debilitating disorders associated with numerous physical and psychiatric problems such as diabetes, obesity, bone-mass loss, infertility, depression, and anxiety (Agras, 2001; Cachelin et al., 1999; Johnson, Spitzer, & Williams, 2001). Yet despite their chronicity and severity, eating disorders largely go undetected and untreated (Cachelin et al., 2001; Cachelin et al., 2006). Women of ethnic minority groups are the most likely group to suffer from unmet mental health needs (Center for Disease Control, 2004; National Women’s Law Center, 2001). Our recent research has demonstrated that few of these women seek treatment, and in even fewer cases is the eating disorder detected and appropriate treatment delivered (Cachelin & Striegel-Moore, 2006). In one of the studies described earlier (Cachelin et al., 2006), only six (8%) of the 75 Mexican American women with clinically significant binge eating related disorders actually had received treatment. It is likely that the impediments to treatment causally impact each other: Health care professionals may under-detect eating disorders in this population because it is unusual for these individuals to seek help, and at the same time these individuals may be reluctant to seek help because of the expectation that they will not receive appropriate treatment. Such findings underscore the great need for the development of treatment that is accessible to Mexican American and other ethnic minority populations.

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Cognitive behavior therapy (CBT) is considered the treatment of choice for BN and BED (National Institute for Clinical Excellence, 2004; Wilson & Fairburn, 2002; Wilson & Shafran, 2005). However, CBT is a costly and not readily available treatment requiring specialized training and expertise. Therefore, research has begun to examine the effectiveness of guided self-help (GSH), which is based on the principles of CBT, as a minimal intervention or first step in the treatment of binge eating related problems. Guided self-help (GSH) is a low intensity intervention in which patients use a self-help manual with only limited support and instruction from either a specialist or non-specialist in clinical or nonclinical settings. GSH is briefer, less costly, and more easily disseminated than CBT, and research with European and European American women indicates that it is efficacious for the treatment of BN and BED (Banasiak, Paxton, & Hay, 2005; Ghaderi, 2006; Grilo & Masheb, 2005; Sysko & Walsh, 2008). Yet no studies to date have examined the use of GSH with ethnic minority populations, who are the groups most in need of accessible and low-cost treatment. Furthermore, research from related areas suggests that for an intervention to be (most) effective with diverse populations, cultural variables and cultural context need to be taken into consideration and incorporated into the intervention (Lozano-Vranich & Petit, 2003; Phinney & Kohatsu, 1997; Snowden & Lieberman, 1994). There is a clear need for the development of culturally specific self-help programs that can be effectively implemented to treat binge eating related disorders in “real world” health care settings. In conclusion, our research supports clinical impressions that eating disorders largely go undetected and untreated, particularly among ethnic minority populations. As a first step in addressing these health problems, effective outreach and educational programs should be developed that increase eating disorder awareness by targeting women and men of ethnic minority groups as well as community health care providers. Given the debilitating and chronic nature of these disorders, future research that furthers knowledge of factors that impede or facilitate help seeking, detection, and treatment should be a priority.

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Cachelin, F. M., Rebeck, R., Veisel, C., & Striegel-Moore, R. H. (2001). Barriers to treatment for eating disorders among ethnically diverse women. International Journal of Eating Disorders, 30, 269-278. Cachelin, F. M., & Regan, P. C. (2006). Prevalence and correlates of chronic dieting in a multi-ethnic U.S. community sample. Eating and Weight Disorders, 11, 91-99. Cachelin, F. M., Schug, R. A., Juarez, L. L., & Monreal, T. K. (2005). Sexual abuse and eating disorders in a community sample of Mexican American women. Hispanic Journal of Behavioral Sciences, 27, 533-546. Cachelin, F. M. & Striegel-Moore, R. H. (2006). Help seeking and barriers to treatment in a community sample of Mexican American and European American women with eating disorders. International Journal of Eating Disorders, 39, 1544-1561. Cachelin, F. M., Striegel-Moore, R. H., Elder, K. A., Pike, K. M., Wilfley, D. E., & Fairburn, C. G. (1999). Natural course outcome of a community sample of women with binge eating disorder. International Journal of Eating Disorders, 25, 45-54. Cachelin, F. M., Striegel-Moore, R. H., & Regan, P. C. (2006). Factors associated with treatment seeking in a community sample of European American and Mexican American women with eating disorders. European Eating Disorders Review, 14, 422-429. Cachelin, F. M., Veisel, C., Striegel-Moore, R. H., & Barzegarnazari, E. (2000). Disordered eating, acculturation and treatment seeking in a community sample of Hispanic, Asian, Black, and White women. Psychology of Women Quarterly, 24, 244-253. Center for Disease Control. (2004). Access to health-care and preventive services among Hispanics and non-Hispanics—United States, 2001-2002. Morbidity and Mortality Weekly Report, 53, 937-941. Fairburn, C. G. (1995). Overcoming binge eating. New York, NY: Guilford Press. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2001). Structured Clinical Interview for DSM-IV-TR Axis I Disorders - Nonpatient edition. New York: Biometrics Research Department, New York State Psychiatric Institute. Franko, D. L., & Striegel-Moore, R. H. (2002). The role of body dissatisfaction as a risk factor for depression in adolescent girls: Are the differences Black and White? Journal of Psychosomatic Research, 53, 975-983. French, S. A., Story, M. T., Downes, B., Resnick, M. D., & Blum, R. W. (1995). Frequent dieting among adolescents: Psychosocial and health behavior correlates. American Journal of Public Health, 85, 695-701. Garfinkel, P. E., Lin, B., Goering, P., Spegg, C., Goldbloom, D., Kennedy, S., Kaplan, A., & Woodside, B. (1995). Bulimia nervosa in a Canadian community sample: Prevalence, comorbidity, early experiences and psychosocial functioning. American Journal of Psychiatry, 152, 1052-1058. Ghaderi, A. (2006). Attrition and outcome in self-help treatment for bulimia nervosa and binge eating disorder: A constructive replication. Eating Behaviors, 7, 300-308. Grilo, C. M., & Masheb, R. M. (2005). A randomized controlled comparison of guided selfhelp cognitive behavioral therapy and behavioral weight loss for binge eating disorder. Behaviour Research and Therapy, 43, 1509-1525. Grilo, C. M., Masheb, R. M., & Wilson, G. T. (2005). Efficacy of cognitive behavioral therapy and fluoxetine for the treatment of binge eating disorder: A randomized doubleblind placebo-controlled comparison. Biological Psychiatry, 57, 301-309.

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Hay, P. (1998). The epidemiology of eating disorder behaviors: An Australian communitybased survey. International Journal of Eating Disorders, 23, 371-382. Herzog, D. B., Hopkins, J. D., & Burns, C. D. (1993). A follow-up study of 33 subdiagnostic eating disordered women. International Journal of Eating Disorders, 14, 261-267. Hoek, H. W., & van Hoeken, D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34, 383-398. Johnson, J. G., Spitzer, R. L., & Williams, J. B. (2001). Health problems, impairment and illnesses associated with bulimia nervosa and binge eating disorder among primary care and obstetric gynecology patients. Psychological Medicine, 31, 1455-11466. Kendler, K. S., MacLean, C., Neale, M., Kessler, R., Heath, A., & Eaves, L. (1991). The genetic epidemiology of bulimia nervosa. American Journal of Psychiatry, 148, 16271637. Lewinsohn, P. M., Striegel-Moore, R. H., Seeley, J. R. (2000). The epidemiology and natural course of eating disorders in young women from adolescence to young adulthood. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 1284-1292. Lozano-Vranich, B., & Petit, J. (2003). The seven beliefs: A step-by-step guide to help Latinas recognize and overcome depression. New York: Rayo/Harper Collins. Marcus, M. D., & Kalarchian, M. A. (2003). Binge eating in children and adolescents. International Journal of Eating Disorders, 34, S47-S57. Mora-Giral, M., Raich-Escursell, R. M., Segues, C., Torras-Clarasó, J., & Huon, G. (2004). Bulimia symptoms and risk factors in university students. Eating & Weight Disorders, 9, 163-169. National Institute for Clinical Excellence (NICE). (2004). Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders. London: NICE Clinical Guideline, No. 9. National Task Force on the Prevention and Treatment of Obesity (NFT). (2000). Dieting and the development of eating disorders in overweight and obese adults. Archives of Internal Medicine, 160, 2581-2589. National Women's Law Center. (2001). Making the grade on women's health: A national and state-by-state report card. Philadelphia: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine and Oregon Health & Science University. Neumark-Sztainer, D., Story, M., Falkner, N. H., Beuhring, T., & Resnick, M. D. (1999). Sociodemographic and personal characteristics of adolescents engaged in weight loss and weight/muscle gain behaviors: Who is doing what? Preventive Medicine, 28, 40-50. Phinney, J., & Kohatsu, E. (1997). Ethnic and racial identity development and mental health. In J. Schulenberg, J. Maggs, & K. Hurrelman (Eds.), Health risks and developmental transitions in adolescence (pp. 420-443). New York: Cambridge University Press. Radloff, L. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401. Regan, P. C., & Cachelin, F. M. (2006). Binge eating and purging in a multi-ethnic community sample. International Journal of Eating Disorders, 39, 523-526. Smolak, L., & Striegel-Moore, R. H. (2001). Challenging the myth of the golden girl: Ethnicity and eating disorders. In R. H. Striegel-Moore, & L. Smolak (Eds.), Eating disorders: Innovative directions in research and practice (pp. 111-132). Washington, DC: American Psychological Association.

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Snowden, L. R., & Lieberman, M. A. (1994). African-American participation in self-help groups. In T. J. Powell (Ed.), Understanding the self-help organization (pp. 50-61). Thousand Oaks, CA: Sage Publications. Striegel-Moore, R. H., & Cachelin, F. M. (2001). Etiology of eating disorders in women. The Counseling Psychologist, 29, 635-661. Striegel-Moore, R. H., Dohm, F. A., Kraemer, H. C., Taylor, C. B., Daniels, S., Crawford, P. B., & Schreiber, G. B. (2003). Eating disorders in White and Black women. The American Journal of Psychiatry, 160, 1326-1331. Sullivan, P. F. (2002). Course and outcome of anorexia nervosa and bulimia nervosa. In C. G. Fairburn, & K. Brownell (Eds.), Eating disorders and obesity (pp. 226-232). New York: The Guilford Press. Sysko, R., & Walsh, T. (2008). A critical evaluation of the efficacy of self-help interventions for the treatment of bulimia nervosa and binge eating disorder. International Journal of Eating Disorders, 41, 97-112. Wilfley, D. E., Friedman, M. A., Dounchis, J. Z., Stein, R. I., Welch, R. R., & Ball, S. A. (2000). Comorbid psychopathology in binge eating disorder: Relation to eating disorder severity at baseline and following treatment. Journal of Consulting and Clinical Psychology, 68, 641-649. Wilson, G. T. & Fairburn, C. G. (2002). Treatments for eating disorders. In P. E. Nathan, & J. M. Gorman (Eds.), A guide to treatments that work, 2nd ed. (pp. 559-592). New York: Oxford University Press. Wilson, G. T., & Shafran, R. (2005). Eating disorders guidelines from NICE. Lancet, 365, 7981.

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In: Binge Eating: Psychological Factors… Editor: Natalie Chambers

ISBN: 978-1-60692-242-2 © 2009 Nova Science Publishers, Inc.

Short Communication C

CHARACTERISTICS OF BINGE EATING IN BULIMIA NERVOSA AND BINGE EATING DISORDER: A REVIEW AND EMPIRICAL INVESTIGATION

Cortney S. Warren¹, Nancy C. Raymond², Susanne S. Lee², Lindsay H. Bartholome² and Susan K. Raatz ² Department of Psychology, University of Nevada, Las Vegas¹ Department of Psychiatry, University of Minnesota Medical School²

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ABSTRACT Bulimia nervosa (BN) and binge eating disorder (BED) are both eating disorders characterized by recurrent binge eating episodes. Although the operational definition of binge eating is essentially the same for BN and BED, understanding potential similarities and differences in binge eating behavior is critical to evaluate the nosological status of BED as a unique diagnosis and to inform treatment and prevention efforts. The overarching purpose of this paper is two-fold: 1) to provide a literature review of data comparing binge eating behavior in individuals with BN and BED; and, 2) to present data examining differences in preferred binge foods and binge eating-related symptoms in a group of women with BN and BED. The literature review revealed many similarities and some important differences between the disorders with regards to binge size, food preferences and macronutrient intake, temporal patterns of eating, and hedonics. Data comparing preferred binge foods and binge eating-related symptoms in women with BN (n = 9) and BED (n = 12) indicated that women with BED identify salty snacks and oilbased foods as preferred binge foods more frequently than women with BN. Additionally, women with BN reported feeling more “miserable or annoyed” following a binge eating episode than women with BED. As a whole, these results suggest that some aspects of binge eating appear similar in women with BN and BED whereas others do not.

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24

Cortney S. Warren, Nancy C. Raymond, Susanne S. Lee et al.

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INTRODUCTION Bulimia nervosa (BN) and binge eating disorder (BED) are both eating disorders characterized by recurrent binge eating episodes. According to the American Psychiatric Association (DSM-IV-TR), a binge eating episode is eating a large amount of food in a short amount of time while feeling a loss of control over what and how much is eaten (2000). This basic definition of binge eating is the same for BN and BED. The only notable diagnostic difference between the disorders is related to the frequency and duration of binge eating behavior: Binge eating associated with some type of compensatory behavior must occur at least twice a week for 3 months to warrant a diagnosis of BN whereas binge eating must occur twice a week for at least 6 months according to the proposed diagnostic criteria for BED (DSM-IV-TR, 2000). Although the DSM-IV-TR (2000) definition of a binge eating episode is essentially the same for BN and BED, understanding potential similarities and differences in binge eating behavior is critical. BED is currently listed as a disorder in need of additional information to warrant a unique diagnostic category. Given the on-going debate regarding the nosological status of BED as a diagnosis (Grilo, et al., 2008), research delineating differences in binge eating behavior in individuals with BN and BED will help determine the clinical utility of BED as a unique disorder. Furthermore, should important differentiating information emerge, potentially unique aspects of binge eating behavior will guide assessment and treatment of each disorder. To further understand binge eating behavior in individuals with BN and BED, the overarching purpose of this paper is two-fold. The first goal is to provide a literature review on data comparing binge eating behavior in women with BN and BED. This review will focus on 4 primary areas of research and discussion: the size of binge eating episodes, types of foods consumed during a binge, temporal patterns of eating, and hedonics of binge eating. Although interrelated, these areas will be discussed separately. A second goal is to add to existing research by testing differences in preferred binge foods and binge eating-related symptoms in a group of women with BN and BED. Prior to discussing existing research, it is important to note that the large majority of research to date examines binge eating either in women with BN or in women with BED compared to a control group (e.g., weight-matched non-eating disordered controls) (See Mitchell, Crow, Peterson, Wonderlich, & Crosby, 1998, and Walsh & Boudreau, 2003, for reviews). In fact, our review of the literature revealed that very few studies have attempted to directly compare binge eating in individuals with BN and BED in a single study. However, some researchers have used identical methodology to examine binge eating behavior in individuals with BN and BED, which lends itself to direct quantitative comparisons (e.g., research studies from Columbia University use the same methods: Cooke, Guss, Kissileff, Devlin, & Walsh, 1997; Goldfein, Walsh, LaChaussée, Kissileff, & Devlin, 1993; Hadigan, Kissileff, & Walsh, 1989; Walsh, Hadigan, Kissileff, & LaChaussee, 1992). Consequently, our review will include research that compares binge eating in individuals with BN to those with BED either in a single study or across studies that employ similar methodologies.

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BINGE SIZE One primary area of comparison in research exploring binge eating is binge size. Binge size is typically operationalized by measuring the total caloric intake a person consumes during a binge. In comparative studies of individuals with BN and BED, binge size is generally measured by comparing the amount of energy (e.g., kcals) consumed during a binge eating episode to non-binge meals, meals of non-eating disordered control participants, or meals of other eating disorder groups (e.g., comparing BN to BED). Overall, research consistently suggests that individuals with BN consume significantly more energy during a binge than on non-binge days and than weight-matched non-eating disordered individuals (e.g., Alpers & Tuschen-Caffier, 2004; Hetherington, Altemus, Nelson, Bernat, & Gold, 1994; Walsh, Kissileff, Cassidy, & Dantzic, 1989). Similarly, individuals with BED appear to consume significantly more on days when they have a binge eating episode than on non-binge days and than weight-matched non-eating disordered controls (e.g., Galanti, Gluck, & Geliebter, 2007; Goldfein, et al., 1993; Guss, Kissileff, Walsh & Devlin, 1994; Raymond, Bartholome, Lee, Peterson, & Crosby, 2007; Sysko, Devlin, Walsh, Zimmerli, & Kissileff, 2007; Walsh & Boudreau, 2003). Research directly comparing binge size in individuals with BN to those with BED yields more inconsistent results, but generally suggests that individuals with BED eat less during a binge eating episode than those with BN. For example, when asked to binge eat on ice cream using methodologically identical laboratory-based protocols, patients with BN consumed substantially more kcals (average = 1,390 kcals; Walsh et al., 1992) than women with BED (average = 743 kcals) (Goldfien et al., 1993). Similarly, in a review and synopsis of the literature on food consumption in laboratory-based studies of binge eating, Mitchell and colleagues (1998) found that the average range of kcals consumed during a binge was smaller for participants with BED than for those with BN. Specifically, BED binges ranged between 1,515 and 2,963 kcals whereas BN binges ranged between 3,031 and 4,479 kcals across all of the studies reviewed. In contrast to these data, one study found no significant differences between women with BN and BED with regard to the quantity of food eaten. In a study of individuals seeking treatment for an eating disorder, Fitzgibbon and Blackman (2000) found that participants with BN did not consume significantly more energy than those with BED based on food records (2799 vs. 2306.5 kcal). However, although not statistically significant, Fitzgibbon and Blackman’s (2000) data suggested a trend towards individuals with BN eating more kcals than individuals with BED. It should also be noted that much controversy surrounds the operational definition of a binge eating episode with regard to binge size (Cooper & Fairburn, 2003; Johnson, Boutelle, Torgrud, Davig, & Turner, 2000; Keel, Mayer, & Harnden-Fischer, 2001; Lawrence, Campbell, Neiderman, & Serpell, 2003). There is no agreed-upon definition of what represents an “objectively large amount of food” and some clinicians question the importance of binge size to the experience of binge eating in individuals with BN and BED (e.g., Keel et al., 2001; Pratt, Niego, & Agras, 1998). For example, in a study exploring differences in psychopathology in women with BN and those who did not exhibit ‘objectively large’ binges but endorsed other symptoms of binge eating (e.g., loss of control), no differences emerged with regard to levels of disinhibition, hunger, dietary restraint, or general psychopathology

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between groups (Keel, et al., 2001). The only significant differences were found with regards to the frequency of binge/purge episodes and impulsivity such that individuals with BN were more impulsive and had more frequent binge/purge episodes (Keel, et al., 2001). In fact, some researchers have suggested that perceived loss of control may be a more fundamental characteristic to binge eating than binge size. This is, in part, because variability in the quality of food consumed and overall caloric consumption can be explained by the subjective feelings of loss of control and the types of food consumed (Gleaves, Williamson, & Barker, 1993; Rossiter, Agras, Telch, & Bruce, 1992). Given the controversy over what constitutes an objectively large amount of food and how fundamental binge size is to ones experience of binge eating, Fairburn and Cooper (1993) suggested labeling eating episodes in which individuals feel a loss of control while eating a small to moderate amount of food as subjective binge eating episodes to differentiate them from their objective counterparts. Future research investigating the importance of binge size to defining what constitutes a binge eating episode will be an essential step in developing diagnostic binge criteria for individuals with BN and BED.

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FOOD PREFERENCES A second primary area of comparison examines food preferences and the types of food consumed during a binge eating episode. Anecdotal experiences and research data suggest that binge episodes often consist primarily of “junk foods” that have high caloric content but little nutrient value. For example, according to dietary food records of a 48 women who selfidentified as non-purging binge eaters, Allison and Tiggemann (2007) found that most binges (89.6%) contained foods that should be eaten most sparingly in a healthy diet because they are low in nutrients but high in calories (i.e., from the top of the food pyramid; fats, sweets, alcohol). Consequently, researchers have investigated whether the types of foods and macronutrient content of binges are important to individuals’ experiences of binge eating. In women with BN, most researchers have found that individuals consume significantly more energy from fat and less energy from protein during a binge eating episode than they do during in a non-binge meal and than non-eating disordered controls eat during a normal meal (e.g., Alpers & Tuschen-Caffier, 2004; Gendall, Sullivan, Joyce, Carter, & Bulik, 1997; Hetherington et al., 1994). Specifically, individuals with BN consume more snack foods and sweet desserts, such as nuts, potato chips, candy, ice cream, and cake, during binge eating episodes than during non-binge meals and than control participants (Hadigan et al., 1989; Rosen, Leitenberg, Fisher, & Khazam, 1986). Although many researchers speculate that binge foods also contain more carbohydrates, because many junk foods high in fat are also high in carbohydrates (e.g., ice cream, sweets), most research indicates no differences between women with BN and controls in carbohydrate intake during a binge (e.g., Alpers & Tuschen-Caffier, 2004; Walsh et al., 1989). Data from individuals with BED appear to be mixed with regard to differences in macronutrient intake during a binge eating episode. Like much research on BN, some researchers have found individuals with BED eat a significantly greater percentage of fat and lesser percentage of protein in their binge meals than controls (Hetherington, et al., 1994; Yanovski, et al., 1992). For example, in a sample of obese binge eaters, Marcus, Wing, and

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Hopkins (1988) found that a large percentage of participants identified sweet foods (54%), salty snacks (46%), cookies (20%), pastries (17%), and ice cream (14%) as preferred binge foods. These foods tend to have a high percentage of fat, sugar, and salt. Other researchers, however, have found that foods consumed during a binge for individuals with BED are similar to nutrients consumed by non-eating disordered participants (Cooke et al., 1997; Goldfein et al., 1993; Raymond, et al., 2007). A recent study by Raymond and colleagues (2007) found no significant differences in macronutrient intake or food types consumed between women with BED and matched controls in a laboratory-based binge study. Similarly, Cooke and colleagues (1997) found very few differences in the types of foods consumed in women with BED and matched controls. In fact, the only significant difference was that women with BED ate more meat than controls, but no differences emerged with regards to carbohydrates, desserts, or vegetables. One explanation for the differences in food type and macronutrient intake between individuals with BN and BED is that individuals with BED may have binge eating episodes in the middle of or following a meal more frequently than individuals with BN. Many individuals with BED report that binges start after eating a typical meal with balanced nutrient content. For example, Allison and Tiggemann (2007) found that the large majority of binge eating episodes occurred during meals (81.2%) as compared to during snacks or “nonmeal” times (18.8%) in a community sample of women who identified as non-purging binge eaters. However, because no psychological testing was done to determine ED diagnosis in this study, it is impossible to determine whether these women would meet diagnostic criteria for BED, BN (non-purging type; BN-NP), or both. More research is needed to determine whether differences in food types and macronutrient intake between individuals with BN and BED emerge because of a tendency to binge following or amidst a meal.

TEMPORAL PATTERNS A third area of investigation relates to temporal patterns of eating. Temporal patterns of eating are important because many etiologic models and theories of what maintains and reinforces binge eating behavior are centered on the effects of severe caloric restriction and unsuccessful dieting. Proponents of dietary restraint theory and restriction theories of binge eating (e.g., Herman & Polivy, 1980; Howard & Porzelius, 1999; Polivy and Herman, 1985) argue that caloric restriction increases the likelihood of binge eating because of it’s physiological (e.g., hunger) and/or psychological consequences (e.g., negative affect, cognitions). Patterns of food restriction can occur in the form of eating less on non-binge days and/or eating less prior to a binge in a single day. Furthermore, following a binge eating episode, individuals often restrict their eating to compensate for the food consumed during the binge, and a cyclical pattern of restriction-binge eating emerges. In line with these theories, research suggests that individuals with BN attempt to diet and restrict food intake (e.g., Mussell, et al., 1997; Rossiter et al., 1992). Individuals with BN often report fasting or extreme dieting between binge eating episodes (Mitchell, Pyle, & Eckert, 1981). For example, in a study of food records of 22 women with BN-NP, Rossiter and colleagues (1992) found that participants ate an average of 2400 kcals on days that included a binge eating episode and 1500 kcals (i.e., less than the daily recommended average

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Cortney S. Warren, Nancy C. Raymond, Susanne S. Lee et al.

of 2000 kcal a day) on binge-free days. Similarly, historical data from a sample of over 200 individuals with BN indicated that 70% started dieting prior to (i.e., at a younger age) engaging in any binge eating behavior (Mussell, et al., 1997). This suggests that individuals with BN may begin restrictive eating before ever engaging in binge eating. Although comparatively more research exists documenting the association between restriction and binge eating for individuals with BN than BED, some data suggests restrictive eating patterns in women with BED (e.g., Agras & Telch, 1998; Howard & Porzelius, 1999; Raymond, Neumeyer, Warren, Lee, & Peterson, 2003). For example, in a random dietary recall study of 12 women with BED and 8 weight- and age-matched controls, Raymond and colleagues (2003) found that women with BED ate significantly fewer calories in the middle of the day (between 11 am and 2 pm) and more calories in the evening (5pm-10pm) than controls. This pattern was apparent for both binge days and non-binge days, suggesting a restriction of calories early in the day leading to a consumption of greater calories later in the day (Raymond et al., 2003). Despite the fact that dietary restriction may play a role in binge eating for both individuals with BN and BED, most research suggests that the link between dietary restriction and binge eating is stronger in individuals with BN than in those with BED. In laboratory feeding studies, individuals with BN frequently consume fewer calories than controls and than patients with BED when asked to eat a meal but not to binge eat (e.g., Walsh & Boudreau, 2003). Additionally, patients with BN have been found to have more dietary restraint than patients with BED (Hay & Fairburn, 1998; Wilfley, Schwartz, Spurell, & Fairburn, 2000). For example, in a sample of women with BN and BED, a strong relationship between restriction and disinhibited eating emerged for individuals with BN, but not for those with BED (Ardovini, Caputo, Todisco, & Grave, 1999). Continued research investigating whether eating characterized by dietary restriction and binge eating adequately represents eating patterns for individuals with BED, as it appears to for individuals with BN, is warranted. Another area of research investigating temporal patterns relates to the timing of macronutrient intake and food consumption. Researchers have postulated that individuals with BN and BED may eat foods of different nutrient types in a different order than noneating disordered individuals. Of particular interest is protein. Hadigan and colleagues (1989) found that while non-eating disordered women began eating meals in a laboratory setting with meat consumption, women with BN began both regular meals and binge eating episodes by consuming dessert and snack foods and delaying the intake of fish and meat. Similarly, a sample of BED patients consumed more protein on days when they did not binge eat than when they did binge eat (Rossiter et al., 1992). A lack sufficient protein intake early in a meal or on non-binge days, coupled with some research described above suggesting that individuals with BN and BED eat less protein over the course of a day than controls (Hetherington, et al., 1994), has lead researchers to consider whether the timing of macronutrient intake may affect binge eating. In a study of women with BN and BED, consuming a high-protein supplement three times a day over 2 weeks yielded fewer binge eating episodes than consuming a high-carbohydrate supplement delivered in the same format (Latner & Wilson, 2004). Additionally, participants reported less hunger and greater fullness, and consumed less food at test meals after consuming the protein supplement than the carbohydrate supplement (673 vs. 856 kcal). Further investigation of the interaction between types of food consumed and the timing of food consumption will help us understand

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ways in which these factors reinforce or encourage future binge episodes and guide treatment planning (e.g., increased protein consumption early in the day).

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HEDONICS A final area of investigation explores pleasant and unpleasant experiences and sensations before and following a binge eating episode (e.g., situational, affective, and cognitive states; tendencies towards impulsivity and compulsivity; experiences of satiety and hunger). Theoretically, many researchers argue that negative affect precipitates binge eating behavior and that the actual binging occurs because it provides temporary relief from the negative emotion (Heatherton & Baumeister, 1991; Hilbert & Tuschen-Caffier, 2007; Waters, Hill, & Waller, 2001). In other words, in the short-term, binging behavior is negatively reinforced because it strongly reduces negative affect that existed pre-binge. However, the long-term consequence of recurrent binge eating is likely an increase in negative mood because the original negative mood will return along with negative feelings about recent binge-related behaviors (e.g., embarrassment for having binged, negative thoughts about oneself and how much/what was eaten, etc.). A large body of research supports the assertion that negative affect precedes binge eating behavior in individuals with BN (e.g., Hilbert & Tuschen-Caffier, 2007; Latner & Wilson, 2004; Smyth, et al., 2007; Waters, et al., 2001) and BED (e.g., Hagan et al., 2002; Hilbert & Tuschen-Caffier, 2007; Masheb & Grilo, 2006; Stein et al., 2007). For example, in a sample of 131 women with BN who completed ratings of mood on a hand-held computer for 2 weeks, Smyth and colleagues (2007) found that patients experienced less positive affect, more negative affect, more anger/hostility, and more stress on days in which they binge ate than on non-binge days. Additionally, ratings of negative affect, anger/hostility, and stress increased in severity up to the binge eating event (defined as the occurrence of at least one binge or vomiting episode) (Smyth et al., 2007). Similarly, in a sample of 54 women seeking treatment for BED, negative affect strongly predicted chaotic eating patterns (Hagan et al., 2002). Specifically, feelings of anger, loneliness, sadness, stress, and boredom predicted uncontrolled eating episodes. As a whole, these data suggest that negative affect precipitates binge episodes for individuals with both disorders. However, other data has not found this pattern. In a laboratory study of 69 women with BED who were subjected to a negative mood induction, Munsch and colleagues (2008) found increases in negative affect had no affect on the amount of food consumed, suggesting that negative mood does not necessarily increase the risk of binge eating behavior (Munsch, Michael, Biedert, Meyer, & Margraf, 2008). The little data that directly compares affect in women with BN and BED preceding a binge suggests that individuals with BN may have more negative mood than women with BED before binging (e.g., Hilbert & Tuschen-Caffier, 2007; Lingswiler, Crowther, & Stephens, 1989). For example, in a study of 20 women with BN and 20 with BED, participant mood was more negative before binge eating than before regular eating and at random assessment for both groups. However, women with BED had less negative mood and less negative cognitions about food and eating compared to the BN group (Hilbert & TuschenCaffier, 2007). Similarly, in a sample of 19 women with bulimic symptoms and 15 non-

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Cortney S. Warren, Nancy C. Raymond, Susanne S. Lee et al.

purging binge eaters, negative affect was significantly higher prior to a binge for women with symptoms of BN than for non-purging binge eaters (Lingswiler, et al., 1989). More data directly comparing affect prior to binge eating in women with BN and BED is needed. Research examining affect following a binge eating episode is more mixed. In line with theories of binge eating and affective regulation, some research suggests that affect improves directly following the binge for individuals with BN and BED. For example, in a group of 131 women with BN, Smyth and colleagues (2007) found rapid decreases in negative affect and anger/hostility within the first 2 hours of binge eating (and purging, when applicable). Conversely, other researchers have found negative mood to worsen following a binge (Hilbert & Tuschen-Caffier, 2007; Stein et al., 2007; Waters et al., 2001; Wegner et al., 2002). In a sample of 33 individuals with BED, Stein and colleagues (2007) found that although participants reported the primary purpose of binge eating was to change their mood to be more positive, paradoxically, mood was significantly more negative immediately following a binge eating episode than before binge eating. Similarly, in a study of 15 women with BN, Waters and colleagues (2001) found that binge eating episodes were followed by a substantial deterioration of mood. If negative affect is not improved following a binge, researchers must determine what is reinforcing the binge eating behavior (besides the possible reinforcing properties of the food itself (e.g., taste, enjoyment of eating)) because these findings are in contrast to most theories delineating what maintains the restriction-binge eating cycle. The little research that directly compares individuals with BN and BED following a binge suggests that women with BN have stronger negative affect following a binge than women with BED. For example, in a sample of treatment-seeking women with BN (n = 29) and BED (n = 49), Mitchell and colleagues found that women with BED reported less physical discomfort and anxiety and more relaxation after binge eating than those with BN (Mitchell et al., 1999). Additionally, participants with BED reported that they enjoyed the taste, texture, and smell of the food while binge eating more often than those with BN. However, the two groups reported similar levels of distress and precipitants associated with binge eating (Mitchell et al., 1999). Similarly, in a sample of 30 women with BN and 35 with BED, Sullivan (2001) found that ratings of anxiety, hostility, and depression were higher for those with BN than those with BED following a binge. It is important to note that general psychopathology may contribute to the hedonics of binge eating. The majority of research suggests that individuals with BN have more significant comorbid psychopathology than individuals with BED (Ardovini et al., 1999; Fichter, Quadflieg, & Brandl, 1993; Grilo, 1998; Hay & Fairburn, 1998; Raymond, Mussell, Mitchell, De Zwaan, & Crosby, 1995; Tasca, Balfour, Kurichh, Potvin-Kent, & Bissada, 2006). For example, in a sample of 100 participants with BED and 31 with BN, Ardovini and colleagues (1999) found higher levels of food disinhibition, cognitive restriction, compulsive eating, clinical severity of eating disorder symptoms, and general mental health problems in individuals with BN than those with BED. On one hand, if individuals with BN have more overall pathology, it is possible that differences in hedonics around eating are more related to another axis I (or axis II) disorder than to the eating disorder. For example, if an individual with BN also struggles with depression, which is inherently associated with a more negative mood state, one could argue that studies of hedonic comparisons that do not account for depressive symptomatology could find a spurious association between negative mood and binge eating. To determine whether variations of negative mood around binge eating were attributable to general

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psychopathology, Hilbert and Tuschen-Caffier (2007) included a measure of psychological health as a covariate in their analysis of hedonics precipitating binge eating. Results indicated that for individuals with BED, negative mood around eating was partially attributable to general psychopathology (e.g., depression and anxiety). These data support the possible role of general psychopathology, including symptoms of depression and anxiety, on hedonics and suggest that individuals with BED who also have higher general pathology may be predisposed to more negative mood proximal to binge eating. On the other hand, differences in comorbid psychopathology do not necessarily mean that there will be differences in the severity of eating pathology or hedonics of binge eating. In a study comparing patients with BN (n = 46), obese patients with BED (n =79), and non-obese patients with BED (n = 37), Barry, Grilo, and Masheb (2003) found that women with BN had higher levels of depression and reported more pathological personality traits with regard to ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, and maturity fears than obese individuals with BED. However, after controlling for comorbid depression and age, differences in personality traits disappeared but differences in eating pathology remained: Individuals with BN and non-obese individuals with BED had a higher drive for thinness than obese individuals with BED; and, individuals with BED (both obese and nonobese) tended to be more dissatisfied with their bodies than individuals with BN. The authors concluded that levels of dysfunctional personality traits were likely more attributable to depressive symptoms, whereas levels of eating-related disturbances in BN and BED were not a result of comorbid depressive symptoms. To complicate matters further, some research has found no differences in psychopathology between the two disorders. In a community sample of 150 women with BED, 48 women with BN-purging type (BN-P), and 15 with BN-NP, groups did not differ with regard to current or lifetime comorbid psychiatric diagnoses of major depression, dysthymia, bipolar disorder, alcohol abuse, panic disorder, social phobia, agoraphobia, or obsessive-compulsive disorder (Striegel-Moore, et al., 2001). They also did not differ with regards to lifetime prevalence of having at least one other axis I disorder: About 80% in each group reported having another diagnosis (BED = 81.3%; BN-P = 89.6%; BN-NP = 71.4%). The only differences between groups emerged with regards to history of anorexia nervosa (AN) and treatment: Women with BN-P and BN-NP were significantly more likely to have a history of AN and women with BN-P were more likely to have been previously treated for an eating disorder than those with BED.

SUMMARY OF LITERATURE REVIEW In summary, research comparing binge size, types of food consumed, temporal patterns of food consumption, and hedonics of binge eating in individuals with BN and BED suggests many similarities and some important differences. With regards to binge size, existing data suggests that individuals with BN and BED appear to eat more during a binge eating episode than weight-matched individuals without an eating disorder and than during a non-binge meal. Additionally, the majority of research suggests that individuals with BED eat less during a binge eating episode than women with BN. However, the importance of binge size to

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the experience of binge eating remains controversial and some argue that the objective size of binges is less important than one’s subjective feelings of loss of control. With regards to the types of foods consumed, the literature suggests that both individuals with BN and BED often binge eat on junk foods that have little nutrient value. Macronutrient data suggests that individuals with BN consume significantly more energy from fat and less from protein during a binge eating episode than they do during a non-binge meal and than non-eating disordered controls eat at a normal meal. Analyses of macronutrient intake in women with BED is mixed, possibly because many individuals with BED report binges start during or after eating a normal meal with balanced nutrient content more frequently than those with BN. More research in this area is needed. Temporal patterns of binge eating suggest that dieting and restrictive eating play a role in binge eating behavior for both disorders. However, the majority of research suggests that the relationship between dietary restriction and binge eating is stronger in individuals with BN than those with BED. Additionally, the interaction between macronutrient intake and the timing of food consumption may be important to predicting binge eating. Some research suggests that women with BN are more likely to eat low-nutrient foods (e.g., desserts, snack foods) early in binge meals whereas individuals with BED may eat a nutritious meal (including meat and fish) prior to consuming low nutrient foods during a binge. Further investigation of the interaction between types of food consumed and the timing of food consumption will guide treatment planning (e.g., increased protein consumption early in the day). Finally, the literature examining hedonic experiences around binge eating suggest negative affect (e.g., anxiety, sadness, anger) precipitates binge episodes for individuals with both disorders. However, research examining hedonic responses following a binge eating episode is mixed: Some studies suggest an improvement in mood while others suggest a deterioration. Comparatively, individuals with BED appear to experience a less negative mood than those with BN following a binge. Future research must examine situational mood states before and after eating while controlling for trait-based moods and comorbid axis I disorders as all of these factors may directly or indirectly influence mood states and binge eating episodes.

CURRENT RESEARCH STUDY Although existing research has provided many important findings about binge eating in individuals with BN and BED, considerably more research is needed. There continues to be controversy over the foods individuals with BN and BED prefer to consume during a binge. Additionally, for a diagnosis of BED, the DSM-IV-TR specifies that individuals must experience distress and that binge eating episodes are associated with at least 3 of the following: eating until uncomfortably full, eating more rapidly than usual, eating when not hungry, eating because of embarrassment, and feeling depressed, disgusted, or guilty about eating (2000). To add to this burgeoning field of research, we compared the self-reported preferred binge foods and binge eating-related symptoms in a sample of 9 women with BN and 12 with BED. Our first research objective was to examine and compare the foods that participants

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requested for a binge eating episode that would take place during a laboratory-based study. Our second research objective was to test and compare the degree to which women with BN and BED endorsed the characteristics of binge eating described by the DSM-IV-TR (2000) criteria (i.e., those listed above).

METHODS Participants 12 women meeting DSM-IV criteria for BED (1994) and 9 women meeting DSM-III-R criteria for BN (1987) were recruited through newspaper advertisements to participate in a paid research study at a large urban university1. Persons were excluded from study participation who reported diagnoses of substance abuse or substance use disorders within six months of participation, any unstable psychiatric or medical condition, recent suicidal ideation, or a history of psychosis. In addition, individuals using psychotropic medications or who endorsed current dieting behavior were excluded from study participation. Participants meeting criteria for BED who had a history of BN or purging behavior were also excluded.

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Measures To determine a diagnosis of BN, the Structured Clinical Interview for DSM-III-R was administered (Spitzer, Williams, Gibbon, & First, 1988). To determine a clinical diagnosis of BED, the Structured Clinical Interview for DSM-IV Axis I Disorders (First, Spitzer, Gibbon, & Williams, 1995) and Axis II disorders (Spitzer, Williams, Gibbon, & First, 1990) were administered. To determine preferred binge foods, a registered dietician interviewed each qualified participant using a semi-structured format. Participants were asked to identify the foods that they prefer to eat during a binge eating episode. Participants could select as many foods as they desired. After the preferred binge foods were identified, all food items were categorized into one the following 11 food categories: (1) bread/cereal/pasta; (2) cheese/milk/yogurt; (3) fruit/juice; (4) meat/fish/poultry/eggs; (5) salty snack foods (e.g., nuts, chips, french fries); (6) sweets; (7) vegetables; (8) mixed food groups (includes Mexican, Chinese, casserole, pasta/sauce dishes, soup, French toast); (9) pizza; (10) oil-based products (e.g., butter, peanut butter, olive oil, salad dressing); and (11) caloric beverages. To assess binge eating symptoms and affective experiences during a binge eating episode, participants completed the Eating Disorder Questionnaire (EDQ; Mitchell, Hatsukami, Eckert, & Pyle, 1985) section on binge eating behavior (section D.2). The binge 1

These data were collected for 2 separate studies (one on BN and one on BED) and studies using data from these participants have been published. Psycho-physiological data for the BN group was reported by Raymond, Eckert, Hamalainen, Evanson, Thuras, Hartman & Faris, 1999 and 24-hour energy intake data of BED participants reported by Raymond, Neumeyer, Warren, Lee & Peterson, 2003. The full protocol for each study can be found in the above articles.

Binge Eating : Psychological Factors, Symptoms and Treatment, edited by Natalie Chambers, Nova Science Publishers, Incorporated, 2009.

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Cortney S. Warren, Nancy C. Raymond, Susanne S. Lee et al.

eating section of the EDQ is comprised of 6-items that evaluate subjective experiences of binge eating. Items are rated on a 5-point Likert-type scale (1 = never, 5 = always).

Procedures All participants were screened over the telephone to determine whether they met basic inclusion/exclusion criteria for study participation. After the initial phone screening, eligible participants were scheduled for an initial evaluation and interviewed to determine whether they met inclusion criteria for the study. If determined to be eligible, a physical exam was completed and the General Clinical Research Center (CRC) dietician dietitian interviewed the participant and administered study questionnaires.

RESULTS Descriptive and demographics characteristics of the two groups are presented in Table 1. As would be expected from previous research, participants with BED were significantly older, heavier in weight, and higher in BMI than those with BN. The two groups were comparable in height and years of education.

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Table 1. Demographic information by diagnostic group

Age (yrs.)

BED M 37.8

SD 7.8

BN M 23.2

SD 6.6

t 4.6

Height (IN) Weight (LB) BMI Education (yrs)

64.9 235.9 39.7 15.4

2.6 27.0 6.2 1.7

65.9 125.7 20.4 14.3

2.7 9.3 0.8 2.0

0.8 11.1 8.7 1.3

p < .001 .45