The addition of a parent and clinician component to the eating disorder examination for children and adolescents

OBJECTIVE: Our goal was to evaluate the addition of parent and clinician reports to the eating disorder examination (EDE) when used with children and adolescents. METHOD: The EDE was completed with 117 children and adolescents with eating disorders (mean age 14.95 +/- 1.91 years). A slightly modified version of the EDE was completed with parents, and clinician summary scores were assigned. Repeated measures analysis was used to compare child, parent, and clinician scores. RESULTS: In those 70 participants with anorexia nervosa (AN) or eating disorder not otherwise specified with a restrictive pattern (EDNOS-R), child scores were significantly lower than parent scores and clinician scores on restraint and weight concerns. On eating concerns and shape concerns, child scores were lower than clinician scores. Participants with bulimia nervosa (BN) or eating disorder not otherwise specified with binge eating or purging (EDNOS-BP), reported more restraint and shape concerns than parents (n = 47), but their scores did not differ from clinician ratings. No differences were seen in this group on weight concerns or eating concerns. CONCLUSION: Parent and clinician reports are particularly important when assessing children and adolescents with AN or EDNOS-R, but may be less critical for those with BN or EDNOS-BP.     

Maladaptive core beliefs and eating disorder symptoms

This study compared maladaptive core beliefs of eating-disordered groups (full and subthreshold syndrome) and healthy controls and investigated the association between eating disorder symptoms and core beliefs. Participants were compared on self-report measures of core beliefs (YSQ) and eating disorder psychopathology (BITE). Anorexia nervosa (AN; both subtypes) and bulimia nervosa (BN) patients had significantly more core beliefs than healthy controls. Binge eating disorder (BED) patients had intermediate scores between AN and BN on the one hand and healthy controls on the other hand. No correlation was found between core beliefs and frequency of binge eating. Frequency of vomiting, laxative misuse and fasting was positively associated with all domains of core beliefs. Patients with eating disorders have some core beliefs which are not directly related to eating, weight or shape. Frequency of purging and fasting behaviors is associated with more severe maladaptive core beliefs. Our data demonstrate the importance of identifying purging and fasting as significant clinical markers.     

Full syndromal versus subthreshold anorexia nervosa,bulimia nervosa,and binge eating disorder: a multicenter study

OBJECTIVE: The diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) establish symptom severity levels, which are used to separate full cases from partial cases. However, the value of these distinctions is unclear. METHOD: Three hundred eighty-five women with full or partial AN, BN, or BED were assessed at entry into a longitudinal study of eating disorders. RESULTS: Stepwise discriminant analysis revealed that full and partial BN were discriminated by the Yale-Brown-Cornell Eating Disorders Scale total scores (kappa =.46). However, it was not possible to discriminate between full and partial AN or BED. Discriminant analysis also demonstrated clear differences between full AN, BN, and BED. DISCUSSION: Full BN can be differentiated from partial BN by more severe eating disorder symptoms, whereas both full and partial AN and full and partial BED appear quite similar. These results emphasize the distinct nature of AN, BN, and BED, as well as the similarities between full and partial cases.     

Recurrent overeating: An empirical comparison of binge eating disorder,bulimia nervosa,and obesity

The goal of the study was to contribute empirical data to the discussion of appropriate diagnostic classification of obese and nonobese, hinging, and nonbinging eating disordered patients. The study consists of two parts: (1) patients with binge eating disorder (BED) (N = 22) are compared to a matched sample of patients with bulimia nervosa (BN) and to 16 patients with obesity (body mass index [BMI] >30). These patient groups were crosssectionally assessed using expert ratings (interview) and self-ratings. (2) A sample of 68 patients with BED were assessed longitudinally on admission and discharge of inpatient treatment and at a 3-year follow-up using the same instruments as in the first study. The study is the first to report longitudinal data on patients with BED. The general pattern of the cross-sectional data was that patients with BN not only had higher scores concerning disturbances of eating behavior and attitude but also for general psychopathology when compared to patients with obesity without marked binges. The scores of patients with BED had an intermediate position between BN and obesity but were closer to BN than to obesity. The BED group (and the obesity group) showed a high degree of body dissatisfaction, which, however, was accounted for by their high body weight. Concerning general psychopathology BED as well as BN had significantly higher scores than the obesity group in the Hopkin's Symptom Checklist (SCL) subscale anger and hostility, in the Complaint List, the PERI Demoralization Scale, and the Beck Depression Inventory. Results of the longitudinal study with BED showed marked improvement in specific and general psychopathology over time. Except for body weight this improvement largely persisted over the 3-year follow-up period. Severity of depression did not predict the course of body weight over time. Data are presented concerning the design of diagnostic criteria for eating disturbed patients not fitting criteria for BN or anorexia nervosa (AN). Arguments pro and contra the introduction of a new BED category in psychiatric diagnostic criteria are discussed. Although there is generally a need for developing or revising the diagnostic criteria for recurrent bingers, our data do not support inclusion of BED (as presently defined) as a separate diagnostic category in DSM-IV. © 1993 by John Wiley & Sons, Inc.     

Perfectionism in women with binge eating disorder.

OBJECTIVE: This study examined self-oriented (SOP), socially prescribed (SPP), and other-oriented (OOP) perfectionism in 127 obese women with binge eating disorder (BED). METHOD: Relationships between eating disorder and general psychopathology variables and SOP, SPP, and OOP were assessed. Levels of SOP, SPP, and OOP in the BED sample were compared with those of 32 normal weight women with bulimia nervosa (BN) and 60 obese non-eating-disordered individuals (NED). Structural equation modeling (SEM) was used to test models of the maintenance of BED. RESULTS: Only SPP was significantly associated with eating disorder variables related to BED. All three groups demonstrated similar levels of SPP and OOP. BN and BED groups scored significantly higher than the NED group on SOP only. SEM resulted in two models with good fits. DISCUSSION: Further research is needed on the roles of SPP and SOP in BED and on weight and shape overconcern in BED maintenance models.     

Body checking and avoidance in overweight patients with binge eating disorder

OBJECTIVE: Repetitive body checking and avoidance are viewed as behavioral manifestations of the core psychopathology of eating disorders (EDs). We examined select body checking and avoidance behaviors in overweight patients with binge eating disorder (BED). METHOD: Three hundred seventy-seven overweight (body mass index [BMI] > or = 25) treatment-seeking BED patients (80 men and 297 women) were administered measures to assess body checking and avoidance, other key behavioral features of EDs (binge eating, dietary restraint, and disinhibition), and the core psychopathology of EDs (overevaluation of weight and shape). RESULTS: The majority of participants reported regularly pinching areas of their body to check for fatness and avoided wearing clothing that made them particularly aware of their body. Significant associations emerged between checking and restraint, and conversely, between avoidance and binge eating. Both checking and avoidance were positively and significantly associated with overevaluation of weight and shape, even after controlling for their unique effects. DISCUSSION: These findings offer support to the potential role of checking and avoidance behaviors in the maintenance of BED.     

Subthreshold binge eating disorder

OBJECTIVE: To examine the clinical features of subthreshold binge eating disorder (BED). METHOD: Participants were recruited directly from the community as part of an ongoing study of risk factors for BED. Forty-four women with subthreshold BED were compared with 44 women with BED and 44 healthy controls on demographic characteristics, body mass index (BMI), eating disorder symptomatology, and psychiatric distress. Diagnoses were established using the Eating Disorder Examination (EDE). Participants completed the EDE-Questionnaire, the Brief Symptom Inventory, and were measured and weighed. RESULTS: Adjusting for significant group differences in BMI, the two eating disorder groups did not differ significantly on measures of weight and shape concern, restraint, psychiatric distress, and history of seeking treatment for an eating or weight problem. DISCUSSION: Given the importance of diagnostic status for access to treatment, further evaluation of the severity criterion specified for BED is needed.     

Comparison of binge eating disorder and bulimia nervosa in a community sample.

OBJECTIVE: This study examined the relationship between binge eating disorder (BED), a newly proposed eating disorder, and bulimia nervosa (BN). METHOD: Three groups recruited from the community were compared: women with BED (n = 150), women with purging BN (n = 48), and women with nonpurging BN (n = 14). RESULTS: The three groups did not differ significantly in education, weight or shape concern, and current or lifetime prevalence of nine major mental disorders. Women with BED, compared with women with purging BN, were older, less likely to have a history of anorexia nervosa, and less likely to have been treated for an eating disorder. Obesity was more commonly associated with BED than with either subtype of BN. DISCUSSION: Our results lend some support to BED as an eating disorder distinct from purging BN. More research is needed to clarify the position of nonpurging BN relative to BED and purging BN.     

Different methods for assessing the features of eating disorders in patients with binge eating disorder: a replication.

OBJECTIVE: To compare different methods for assessing the features of eating disorders in patients with binge eating disorder (BED). RESEARCH METHODS AND PROCEDURES: A total of 47 participants with BED were administered the Eating Disorder Examination (EDE) Interview and completed the EDE-Questionnaire (EDE-Q) at baseline. A total of 37 participants prospectively self-monitored their eating behaviors daily for 4 weeks and then completed another EDE-Q. RESULTS: At baseline, the EDE and the EDE-Q were significantly correlated on frequencies of objective bulimic episodes (binge eating), overeating episodes, and on the dietary restraint, eating concern, weight concern, and shape concern subscales. Mean differences in the EDE and EDE-Q frequencies of objective bulimic episodes and overeating were not significant but scores on the four subscales differed significantly, with the EDE-Q yielding higher scores. At the 4-week point, the EDE-Q retrospective 28-day assessment was significantly correlated with the prospective daily self-monitoring records for frequency of objective bulimic episodes and the mean difference between the methods was not significant. The EDE-Q and self-monitoring findings for subjective bulimic episodes and objective overeating differed significantly. DISCUSSION: In patients with BED, the three assessment methods showed some areas of acceptable convergence.     

Predicting the outcome of eating disorders using structural equation modeling

OBJECTIVE: There is a need for models that predict accurately the course of mental disorders. METHOD: Eating-disordered female inpatients were assessed longitudinally at the beginning of treatment (t1), at the end of treatment (t2), at 2 or 3-year follow-up (t3), and at 6-year follow-up (t4). The sample consisted of 196 women with bulimia nervosa (BN) purging type, 103 women with anorexia nervosa (AN), and 68 women with binge eating disorder (BED; N=367). Confirmatory factor analysis and path analysis were used to predict the women's status at 6-year follow-up. RESULTS: The results for BN and BED show that the specific eating disorder pathology was influenced mainly by specific eating disorder pathology at earlier time points and not by non-eating-specific (general) psychopathology. Similarly, general psychopathology was influenced mainly by general psychopathology at earlier time points. For AN patients, both categories of psychopathology (eating specific and general) were relevant for the 6-year outcome. The potential impact of 14 factors on the level of pathology was estimated (a) at baseline (at the beginning of treatment), (b) during the course of illness (baseline controlled), and (c) on the 6-year outcome of eating disorders (baseline and course controlled). Although there were many correlations between potential factors and baseline pathology, there was only a limited number of significant correlations with the 6-year outcome. This effect was mediated largely by the level of general psychopathology. DISCUSSION: The models for outcome prediction based on structural equation modeling techniques were very similar for BN and BED. For both BN and BED, there were almost entirely separate predictions for the specific eating disorder on the one hand and non-eating-related (general) psychopathology on the other hand. This was true to a lesser degree for AN. CONCLUSIONS: The use of refined path analytic methods in follow-up studies on larger general populations will be helpful to increase our understanding of the course of illness of psychiatric disorders.     

Teasing history, onset of obesity, current eating disorder psychopathology, body dissatisfaction, and psychological functioning in binge eating disorder

OBJECTIVE: The primary goal of this study was to examine associations among teasing history, onset of obesity, current eating disorder psychopathology, body dissatisfaction, and psychological functioning in women with Binge Eating Disorder (BED). RESEARCH METHODS AND PROCEDURES: Subjects were 115 female adults who met DSM-IV criteria for BED. Measurements assessing teasing history (general appearance [GAT] and weight and size [WST] teasing), current eating disorder psychopathology (binge frequency, eating restraint, and concerns regarding eating, shape, and weight), body dissatisfaction, and psychological functioning (depression and self-esteem) were obtained. RESULTS: History of GAT, but not WST, was associated with current weight concerns and body dissatisfaction, whereas both GAT and WST were significantly associated with current psychological functioning. Patients with earlier onset of obesity reported more WST than patients with later onset of obesity, but the groups did not differ significantly in GAT, current eating disorder psychopathology, body dissatisfaction. or psychological functioning. Obese women reported more WST than non-obese women, but no differences in GAT or the other outcome variables were observed. Higher frequency of GAT was associated with greater binge frequency in obese women, and with greater eating restraint in non-obese women. DISCUSSION: Although physical appearance teasing history is not associated with variability in most eating disorder psychopathology, it is associated with related functioning, most notably body dissatisfaction, depression, and self-esteem. Our findings also suggest that the age of onset of obesity and current body mass index status in isolation are not associated with eating psychopathology or associated psychological functioning in adult patients with BED.     

Predictors of relapse following successful dialectical behavior therapy for binge eating disorder

OBJECTIVE: To identify predictors of relapse at 6-month follow-up for women with binge eating disorder (BED). METHOD: Participants were 32 women with BED who had initially achieved abstinence from binge eating after 20 weeks of dialectical behavior therapy (DBT) adapted for patients with BED. Posttreatment predictor variables included the subscales Restraint, Weight Concerns, and Shape Concerns from the Eating Disorders Examination (EDE), the Emotional Eating Scale score, the Rosenberg Self-Esteem Scale, body mass index, and early versus late age of binge eating onset. RESULTS: The largest effect sizes for predicting relapse were found with early onset of binge eating and higher EDE Restraint scores. DISCUSSION: Previous findings that earlier age of onset (age 16 years or younger) is linked to less successful treatment outcome are now extended to the 6-month follow-up assessment. The finding that higher restraint scores after treatment predict relapse adds to the literature concerning the role of restraint in patients with BED.     

On the relation of attempting to lose weight, restraint, and binge eating in outpatients with binge eating disorder

OBJECTIVE: To examine the relationship among attempts to lose weight, restraint, and eating behavior in outpatients with binge eating disorder (BED). RESEARCH METHODS AND PROCEDURES: Participants were 93 consecutive outpatients evaluated for a clinical trial who met Diagnostic and Statistical Manual, Fourth edition criteria for BED. The Eating Disorder Examination Interview was administered to assess attempts at weight loss, restraint, different forms of overeating, and the attitudinal psychopathology of eating disorders (i.e., concerns regarding eating, shape, and weight). In addition, the Three-Factor Eating Questionnaire was used to assess cognitive restraint, hunger, and disinhibition. Psychometrically established measures were given to assess body dissatisfaction, depression, and self-esteem. RESULTS: The majority of participants (75.3%; N = 70) reported attempting to lose weight, but only 37.6% (N = 35) reported dietary restraint on at least half the days of the month. Dietary restraint and cognitive restraint were not associated with any form of binge eating or overeating. Dietary restraint and cognitive restraint were positively correlated with weight concern, shape concern, and body dissatisfaction, and negatively correlated with body mass index. To further examine the interplay between attempting to lose weight and restraint, three study groups were created: unrestrained nonattempters (21.5%, N = 20), unrestrained attempters (40.9%; N = 38), and restrained attempters (34.4%; N = 32). The three groups did not differ significantly on binge eating or other eating behaviors; however, significant differences were observed for weight concern, shape concern, and body dissatisfaction. DISCUSSION: Attempts to lose weight and restraint are not synonymous for patients with BED. Although 75.3% of BED patients reported that they were attempting to lose weight, only 37.6% reported dietary restraint on at least half the days of the previous month. While restraint was negatively associated with body mass index, it was not related to binge eating or overeating. Our findings raise questions about prevailing models that posit restraint as a predominant factor in the maintenance of binge eating in BED.     

Research on energy expenditure in individuals with eating disorders: a review

OBJECTIVE: This study reviews the published research on energy expenditure in individuals with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). METHOD: Individual studies are reviewed and their results summarized. RESULTS: The most consistent finding is evidence of reduction in resting energy expenditure (REE) in patients with AN, which increases with increased energy intake and body weight. Data regarding BN are inconsistent. Three available studies in subjects with BED have not found evidence of changes in energy expenditure corrected for lean body mass compared with obese non-binge eaters. DISCUSSION: The ability to reliably and cost-effectively measure REE may aid in the refeeding of patients with AN where REE is reduced. Changes in BN and BED subjects have yet to be identified consistently.     

Research on energy expenditure in individuals with eating disorders: a review

OBJECTIVE: This study reviews the published research on energy expenditure in individuals with anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). METHOD: Individual studies are reviewed and their results summarized. RESULTS: The most consistent finding is a reduction in resting energy expenditure (REE) in patients with AN, which increases with increased energy intake and body weight. Data regarding BN are inconsistent. Three available studies in subjects with BED have not found evidence of changes in energy expenditure corrected for lean body mass compared with obese non-binge eaters. DISCUSSION: The ability to measure REE reliably and cost-effectively may aid in the refeeding of patients with AN in whom REE is reduced. Changes in individuals with BN and BED have yet to be consistently identified.     

Binge-eating disorder in Brazilian women on a weight-loss program

OBJECTIVE: To examine binge-eating disorder (BED) and its association with obesity, weight patterns, and psychopathology in a Brazilian sample of female participants of a weight-loss program in S?o Paulo, Brazil. RESEARCH METHODS AND PROCEDURES: Two hundred and seventeen overweight (body mass index >/= 25 kg/m(2)) women, ages 15 to 59 years, enrolled in the Weight Watchers Program were recruited for the study at a program branch meeting after completing the Questionnaire on Eating and Weight Patterns-Revised, Beck Depression Inventory, and the Toronto Alexithymia Scale-20. Participants were categorized into four groups: those who met questionnaire criteria for BED, those who met questionnaire criteria for bulimia nervosa (BN), those that reported binge eating but did not meet all the criteria for any eating disorder (BE), and those with no eating disorder symptoms (No ED). Groups were compared on measures of weight, depressive symptoms, and alexithymia. RESULTS: Binge eating was frequently reported by women in this study (BED, 16.1%; BN, 4.6%; BE, 22.6%). BED women had significantly higher body mass index, greater highest weight ever, and more frequent weight cycling than the No ED group. BED women also reported more depressive symptoms than BE and No ED women, and were more alexithymic than the No ED group. BE women presented more frequent weigh cycling and were also more depressed and alexithymic than the No ED group. DISCUSSION: BED is not uncommon in overweight Brazilian women, and similar to North American and European samples, it is associated with overweight and higher levels of psychopathology in this population.     

Changes in weight and body image over time in women with eating disorders

BACKGROUND: This study examined the changes in body image and weight in young women with an adolescent eating disorder, relative to women without an eating disorder (noED). METHOD: Three diagnostic groups, anorexia nervosa (AN; n = 10), bulimia nervosa (BN; n = 27), and binge eating disorder (BED; n = 42) and three comparison groups (noED; n = 659 each) were compared on body mass index (BMI) and self-reported current body size, ideal body size, and weight dissatisfaction. Dependent variables were examined 2 and 1 year before the onset, the onset year, and 1 and 2 years after the onset of the eating disorder in a model that was adjusted for ethnicity and BMI. RESULTS: BMI was lower in the AN group at all time points except 2 years before onset. AN girls evidenced a significantly stronger relation between BMI and current self-ratings and weight dissatisfaction than noED girls. BMI did not differ between the BN group and the noED group. Girls with BN reported larger current body sizes and greater weight dissatisfaction across all time points. The BED group had higher BMI than the noED group across time. BED girls reported greater current body size ratings and weight dissatisfaction than the noED girls. Girls with AN, BN, or BED did not differ from the noED girls on body ideal ratings. DISCUSSION: Body weight seems to influence perception of body size more so for girls with AN than for noED girls. No support was found for an accelerated weight gain over time for BN. Weight may increase over time for the BED group relative to the noED group, but larger studies are needed. Across all three groups, ideal body size appears to be unrelated to diagnostic status. Rather, the risk for developing an eating disorder appears to arise from size overestimation and related weight dissatisfaction.     

Binge eating disorder: Its further validation in a multisite study

Binge eating disorder (BED) is a new eating disorder that describes the eating disturbance of a large number of individuals who suffer from recurrent binge eating but who do not regularly engage in the compensatory behaviors to avoid weight gain seen in bulimia nervosa. This multisite study of BED involved 1,785 subjects drawn from 18 weight control programs, 942 subjects from five nonpatient community samples, and 75 patients with bulimia nervosa. Approximately 29% of subjects in weight control programs met the criteria for BED. In the nonpatient community samples BED was more common than purging bulimia nervosa. The validity of BED was supported by its strong association with (1) impairment in work and social functioning, (2) overconcern with body/shape and weight, (3) general psychopathology, (4) significant amount of time in adult life on diets, (5) a history of depression, alcohol/drug abuse, and treatment for emotional problems. © 1993 by John Wiley & Sons, Inc.     

Family characteristics of binge-eating disorder patients

Binge-eating disorder (BED) has been described and proposed as a new eating disorder diagnosis. Although studies have examined the characteristics of the family members of patients with anorexia nervosa (AN) and bulimia nervosa (BN), little is known about the characteristics of family members of BED patients. The Family Environment Scale (FES) was administered to 88 patients with a DSM-III-R diagnosis of an eating disorder (23 AN, 45 BN, 20 BN+AN), as well as 43 patients with BED as defined by DSM-IV criteria. Statistically significant differences were found among the groups on the cohesion, expressiveness, and active-recreational subscales of the FES by analysis of variance (ANOVA). On the cohesion subscale, significant differences were noted between AN and BED, p < .019, with AN scoring higher than BED. On the expressiveness subscale, significant differences were noted for BED and BN, p < .016, with BN scoring higher than BED. On the active-recreational subscale, there were significant differences for BED versus BN, BED versus AN, and BED versus AN+BN (p < .0001), with BED scoring lower than all other groups. Comparison of BED data to existing normative data yielded significant differences on the cohesion, expressiveness, conflict, independence, intellectual-cultural, active-recreational, and control subscales, with BED patients scoring higher than controls on the conflict and control subscales and lower than controls on all others. These data represent the first study of family characteristics of BED patients utilizing DSM-IV criteria, and provide a beginning understanding of family factors that may be useful in treatment. © 1998 by John Wiley & Sons, Inc. Int J Eat Disord 23:145–151, 1998.     

Stress response and binge eating disorder

In clinical practice, obese patients report stress as a primary trigger for binge eating. However, the biological mechanism underlying this relationship is poorly understood. This paper presents, a theoretical overview of how cortisol secretion, a major component of the stress response, could play a role in binge eating, given that exogenous glucocorticoids can lead to obesity by increasing food intake. I will discuss findings from recent studies demonstrating links between laboratory stress, cortisol, food intake and abdominal fat in humans. Cortisol is elevated following laboratory stressors in women with anorexia nervosa (AN), bulimia nervosa (BN), and obesity, but has not been widely studied in women with binge eating disorder (BED). Additionally, I will review recent findings demonstrating a greater cortisol response to stress in obese women with BED compared to non-BED.