Time-of-day and day-of-week patterns of binge eating and relevant psychological vulnerabilities in binge-eating disorder.

OBJECTIVE: The present study sought to characterize the temporal patterns of binge eating and theorized maintenance factors among individuals with binge-eating disorder (BED). METHOD: Ecological momentary assessment of 112 individuals and mixed-effects models were used to characterize the within- and between-day temporal patterns of eating behaviors (binge eating, loss of control only eating, and overeating only), positive and negative affect, emotion regulation difficulty, and food craving. RESULTS: Risk for binge eating and overeating only was highest around 5:30 p.m., with additional binge-eating peaks around 12:30 and 11:00 p.m. In contrast, loss of control eating without overeating was more likely to occur before 2:00 p.m. Risk for binge eating, loss of control only eating, and overeating only did not vary across days in the week. There was no consistent pattern of change in negative affect throughout the day, but it decreased slightly on the weekend. Positive affect showed a decrease in the evenings and a smaller decrease on the weekend. The within-day patterns of food craving, and to some extent emotion regulation difficulty, resembled the pattern of binge eating, with peaks around meal times and at the end of the night. DISCUSSION: Individuals with BED appear most susceptible to binge-eating around dinner time, with heightened risk also observed around lunch time and late evening, though the effects were generally small. These patterns appear to most strongly mimic fluctuations in craving and emotion dysregulation, although future research is needed to test the temporal relationships between these experiences directly. PUBLIC SIGNIFICANCE: It is unknown which times of the day and days of the week individuals with binge-eating disorder are most at risk for binge eating. By assessing binge-eating behaviors in the natural environment across the week, we found that individuals are most likely to binge in the evening, which corresponds to the times when they experience the strongest food craving and difficulty with regulating emotions.

Terminal anorexia nervosa cannot currently be identified.

OBJECTIVE: To review the recent literature on the proposed entity of "terminal anorexia nervosa." METHOD: Review of recent literature on the concept of "terminal AN" as well as past and supporting work. RESULTS: The cases and proposed definitions are reviewed, as is the growing literature on this topic. Problems exist with predicting outcomes and thus, determining futility, as well as about capacity for decision-making. DISCUSSION: To make decisions about treatment futility, the existing database for predicting AN course and treatment response must expand greatly. In addition, while decisional capacity is central to the debate, its determination may be unusually complex in this situation. The gaps identified point to extensive needs for future research, but they also indicate that the concept of "terminal AN" cannot be defined at present and should not be used. PUBLIC SIGNIFICANCE: Anorexia nervosa is challenging to treat, and it often lasts for years. There is debate about whether palliative care or medical aid in dying should be considered. Identifying who has a terminal case of AN is important for this question, but we have limited ability to predict a given individual's outcome at present, and there are concerns about the ability of those with AN to make treatment decisions. This means the concept of "terminal AN" should not currently be used.

"Feeling fat," disgust, guilt, and shame: Preliminary evaluation of a mediation model of binge-eating in adults with higher-weight bodies.

"Feeling fat" is a subjective state that theoretically contributes to the maintenance of binge eating (BE). However, feeling fat, and its relation to BE among individuals with higher-weight bodies, has been infrequently studied. This study proposes a momentary-level model in which negative moral emotion states (disgust, guilt, shame) mediate the association between feeling fat and binge eating. In this study, 50 adults with higher-weight bodies (MBMI=40.3 ± 8.5 kg/m2; 84% female) completed a two-week ecological momentary assessment protocol, which measured experiences of feeling fat, emotion states, and binge-eating behavior. Univariate generalized linear mixed models (GLMM) evaluated the momentary associations among levels of feeling fat at Time 1, emotion states at Time 2, and binge eating at Time 2, controlling for Time 1 emotion states. GLMM results suggest that increases in each emotion from Time 1 to Time 2 mediated the association between Time 1 feeling fat and Time 2 binge eating. When modeled simultaneously within one multivariate multilevel structured equation model, disgust appeared to drive the relation between feeling fat and binge eating, over and above guilt and shame. Although preliminary, findings suggest increases in negative moral emotions, particularly disgust, mediate the feeling fat-binge eating association in adults with higher-weight bodies.

Naturalistically assessed associations between physical activity, affective functioning, and binge eating among adults with binge-eating disorder.

Binge-eating disorder (BED) is associated with overweight/obesity, physical inactivity, and disturbances in affective functioning. While research suggests that physical activity (PA) may have beneficial effects on BED symptoms, little is known about the daily correlates of PA. As a first step in understanding the processes linking PA and binge eating, this study examined associations between PA (i.e., self-reported time engaged in moderate-to-vigorous PA), affective functioning (i.e., positive and negative affect, body satisfaction, emotion regulation), and eating-related cognitions and behaviors (i.e., craving, overeating, loss of control eating) measured via ecological momentary assessment (EMA). Adults with BED (N = 91) completed a seven-day EMA protocol during which they completed repeated measures of these variables. Results indicated individuals who reported greater time engaged in PA over the EMA protocol evidenced higher positive affect and body satisfaction, and lower overeating (between-subjects effects). No significant within-subjects effects were observed. Findings demonstrate that individual differences in PA levels were related to more adaptive affective functioning and eating regulation in daily life. Results highlight the relevance of PA in BED, and the need for future studies to identify the timescale of these relationships using objective measurements of PA.

Association between objective and subjective binge eating and psychopathology during a psychological treatment trial for bulimic symptoms.

Although loss of control (LOC) while eating is a core construct of bulimia nervosa (BN), questions remain regarding its validity and prognostic significance independent of overeating. We examined trajectories of objective and subjective binge eating (OBE and SBE, respectively; i.e., LOC eating episodes involving an objectively or subjectively large amount of food) among adults participating in psychological treatments for BN-spectrum disorders (n = 80). We also explored whether changes in the frequency of these eating episodes differentially predicted changes in eating-related and general psychopathology and, conversely, whether changes in eating-related and general psychopathology predicted differential changes in the frequency of these eating episodes. Linear mixed models with repeated measures revealed that OBE decreased twice as rapidly as SBE throughout treatment and 4-month follow-up. Generalized linear models revealed that baseline to end-of-treatment reductions in SBE frequency predicted baseline to 4-month follow-up changes in eating-related psychopathology, depression, and anxiety, while changes in OBE frequency were not predictive of psychopathology at 4-month follow-up. Zero-inflation models indicated that baseline to end-of-treatment changes in eating-related psychopathology and depression symptoms predicted baseline to 4-month follow-up changes in OBE frequency, while changes in anxiety and self-esteem did not. Baseline to end-of-treatment changes in eating-related psychopathology, self-esteem, and anxiety predicted baseline to 4-month follow-up changes in SBE frequency, while baseline to end-of-treatment changes in depression did not. Based on these findings, LOC accompanied by objective overeating may reflect distress at having consumed an objectively large amount of food, whereas LOC accompanied by subjective overeating may reflect more generalized distress related to one's eating- and mood-related psychopathology. BN treatments should comprehensively target LOC eating and related psychopathology, particularly in the context of subjectively large episodes, to improve global outcomes.

Examining the utility of narrowing anorexia nervosa subtypes for adults.

OBJECTIVE: The purpose of this investigation was to examine whether narrowing the criteria of anorexia nervosa (AN) subtypes among adults based on further delineations of current binge eating and purging (i.e., binge eating only, purging only, binge eating and purging, and restricting only) improves the potential clinical utility of the current DSM-5 system that specifies two types (i.e., current binge eating and/or purging and restricting, specified as the absence of current binge eating and/or purging). METHOD: Self-reported eating disorder and psychiatric symptoms based on the Eating Disorder Questionnaire were examined in 347 adults from a multisite clinical sample who met DSM-IV criteria for AN. Classification based on binge eating and purging symptoms yielded the following subtypes: 118 restricting only (AN-R; no current binge eating or purging); 133 binge eating and purging (AN-B & P; current binge eating and purging); 43 binge eating only (AN-B; current binge eating and no current purging); and 53 purging only (AN-P; current purging and no current binge eating). RESULTS: The AN-R group had lower current body mass index compared to AN-B & P and AN-P with no group differences in highest, lowest, or desired body mass index. The probability of amenorrhea was higher for the AN-R and AN-B & P groups than the AN-P group. The probability of diet pill use was elevated for the AN-B & P and AN-P groups compared to the AN-R group. The AN-P group also had a higher probability of fasting than the AN-R group. The probability of substance use including tobacco was lower in the AN-R group than the other three groups. No group differences were found on measures of hospitalization, body image, physical symptoms, exercise, or dieting behaviors. CONCLUSIONS: These findings do not support the validity or clinical utility of classifying AN into narrower subtypes based on current binge eating, purging, and binge eating with purging given that few differences were found among groups who reported any combination of current binge eating and purging. Future research is needed to replicate these findings and to further examine the AN subtype classification schemes.

Negative affect prior to and following overeating-only, loss of control eating-only, and binge eating episodes in obese adults.

OBJECTIVE: The objective was to examine the trajectory of five types of negative affect (global negative affect, fear, guilt, hostility, sadness) prior to and following three types of eating episodes (overeating in the absence of loss of control [OE-only], loss of control eating in the absence of overeating [LOC-only], and binge eating) among obese adults using ecological momentary assessment (EMA). METHOD: Fifty obese adults (84% female) completed a two-week EMA protocol during which they were asked to record all eating episodes and rate each episode on continua of overeating and loss of control. Momentary measures of global negative affect, fear, guilt, hostility, and sadness were assessed using an abbreviated version of the Positive and Negative Affect Schedule (PANAS). Trajectories for each of the five types of negative affect were modeled prior to and following episodes of OE-only, LOC-only, and binge eating. RESULTS: Consistent with previous findings, global negative affect and Guilt increased prior to and decreased following binge eating episodes (all ps < .05). Guilt also decreased following OE-only episodes (p < .05). DISCUSSION: These results are consistent with the affect regulation model of binge eating and suggest that binge eating may function to regulate global negative affect, and more specifically, guilt among obese adults. These data suggest that the relationship between negative affect and binge eating may not be unique to individuals with clinical eating disorders and indicate that targeting negative affect may be an effective strategy for the treatment of binge eating in the context of obesity.

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

OBJECTIVE: The current study examined behavioral, emotional, and situational factors involved in purging among women with anorexia nervosa (AN). METHOD: Women with AN (n=118) completed a two-week ecological momentary assessment protocol involving daily reports of eating disorder behaviors, mood, and stressful events. Generalized estimating equations examined the likelihood and context of purging following eating episodes involving both overeating and loss of control (binge eating; BE); loss of control only (LOC); overeating only (OE); and neither loss of control nor overeating (non-pathological eating; NE). RESULTS: Relative to NE, purging was more likely to occur following BE, LOC, and OE (Wald chi-square = 18.05; p < .001). BE was more strongly associated with subsequent purging than LOC but not OE; the latter two did not differ from one another. Negative affect predicted purging following NE (Wald chi-square = 7.71; p = .005). DISCUSSION: Binge eating involving large amounts of food was the strongest predictor of purging in AN, which challenges the notion that loss of control is the most salient aspect of experiencing distress in bulimia nervosa and BE disorder. Parallel to findings from the BE literature, negative affect strongly predicted purging following NE. Further research should clarify the function and triggers of purging in AN.

Relationship between daily affect and overeating-only, loss of control eating-only, and binge eating episodes in obese adults.

The two objectives of the current study were: (1) to identify daily patterns of negative affect (NA) in obese individuals; and (2) to determine whether daily affect patterns were related to overeating without loss of control (OE-only), loss of control eating without overeating (LOC-only), and binge eating (BE) episodes. Fifty obese (BMI=40.3 ± 08.5) adults (84.0% female) completed a two-week ecological momentary assessment protocol during which they completed assessments of NA and indicated whether their eating episodes were characterized by OE and/or LOC. Latent growth mixture modeling (LGMM) was used to identify daily trajectories of NA. GEE analysis was used to determine whether daily affect trajectories were differentially related to the frequency of OE-only, LOC-only, and BE episodes. The LGMM analyses identified nine unique trajectories of NA. Significantly higher frequencies of OE-only and BE episodes occurred on days characterized by high or increasing levels of NA. There were no significant differences between classes for the frequency of LOC-only episodes. These data suggest that NA may act as an antecedent to OE-only and BE episodes and that targeting "problematic affect days" may reduce the occurrence of OE-only and BE episodes among obese individuals.

Picking or nibbling: frequency and associated clinical features in bulimia nervosa, anorexia nervosa, and binge eating disorder.

OBJECTIVE: Picking or ribbling (P&N) is a newly studied eating behavior characterized by eating in an unplanned and repetitious manner in between meals and snacks. This behavior seems to be related to poorer weight loss outcomes after bariatric surgery for weight loss in severely obese patients, but clarification is still required regarding its value in other clinical samples. The purpose of this study was to investigate the frequency of P&N across different eating disorder samples, as well as to examine its association with psychopathological eating disorder features. METHOD: Our sample included treatment-seeking adult participants, recruited for five different clinical trials: 259 binge eating disorder (BED); 264 bulimia nervosa (BN), and 137 anorexia nervosa (AN). Participants were assessed using the Eating Disorders Examination interview before entering the clinical trials. RESULTS: P&N was reported by 44% of the BED; 57.6% of the BN; and 34.3% of the AN participants. No association was found between P&N and BMI, the presence of compensatory behaviors, binge eating, or any of the eating disorder examination subscales. DISCUSSION: This study suggests that P&N behavior is highly prevalent across eating disorder diagnoses, but it is not associated with psychopathology symptoms or other eating disordered behaviors.

Race/ethnicity, education, and treatment parameters as moderators and predictors of outcome in binge eating disorder.

OBJECTIVE: Binge eating disorder (BED) is prevalent among individuals from minority racial/ethnic groups and among individuals with lower levels of education, yet the efficacy of psychosocial treatments for these groups has not been examined in adequately powered analyses. This study investigated the relative variance in treatment retention and posttreatment symptom levels accounted for by demographic, clinical, and treatment variables as moderators and predictors of outcome. METHOD: Data were aggregated from 11 randomized, controlled trials of psychosocial treatments for BED conducted at treatment sites across the United States. Participants were N = 1,073 individuals meeting criteria for BED including n = 946 Caucasian, n = 79 African American, and n = 48 Hispanic/Latino participants. Approximately 86% had some higher education; 85% were female. Multilevel regression analyses examined moderators and predictors of treatment retention, Eating Disorder Examination (EDE) global score, frequency of objective bulimic episodes (OBEs), and OBE remission. RESULTS: Moderator analyses of race/ethnicity and education were nonsignificant. Predictor analyses revealed African Americans were more likely to drop out of treatment than Caucasians, and lower level of education predicted greater posttreatment OBEs. African Americans showed a small but significantly greater reduction in EDE global score relative to Caucasians. Self-help treatment administered in a group showed negative outcomes relative to other treatment types, and longer treatment was associated with better outcome. CONCLUSIONS: Observed lower treatment retention among African Americans and lesser treatment effects for individuals with lower levels of educational attainment are serious issues requiring attention. Reduced benefit was observed for shorter treatment length and self-help administered in groups.

Proposed diagnostic criteria for night eating syndrome.

OBJECTIVE: To propose criteria for diagnosis of the night eating syndrome (NES). METHOD: An international research meeting was held in April 2008, and consensus criteria for NES diagnosis were determined. RESULTS: The core criterion is an abnormally increased food intake in the evening and nighttime, manifested by (1) consumption of at least 25% of intake after the evening meal, and/or (2) nocturnal awakenings with ingestions at least twice per week. Awareness of the eating episodes is required, as is distress or impairment in functioning. Three of five modifiers must also be endorsed. These criteria must be met for a minimum duration of 3 months. DISCUSSION: These criteria help standardize the definition of NES. Additional aspects of the nosology of NES yet to be fully elaborated include its relationship to other eating and sleep disorders. Assessment and analytic tools are needed to assess these new criteria more accurately.

A review of nighttime eating disorders.

Nighttime eating is categorized as either night eating syndrome (NES) or sleep-related eating disorder (SRED). These conditions represent an interruption in the overnight fast that characterizes human sleep. A critical review of the literature on NES and SRED will suggest that they are situated at opposite poles of a disordered eating spectrum. NES could be considered an abnormality in the circadian rhythm of meal timing with a normal circadian timing of sleep onset. Conversely, the feeding behavior in SRED is characterized by recurrent episodes of eating after an arousal from nighttime sleep with or without amnesia. Both conditions are often relentless and chronic. Multiple definitions of night eating have limited our ability to determine the exact prevalence of NES. Studies have suggested that central nervous system (CNS) serotonin modulation may lead to an effective treatment of NES. SRED is frequently associated with other sleep disorders, in particular parasomnias. Early studies have shown that the anti-seizure medication topiramate may be an effective treatment for SRED.

Co-occurrence of binge eating disorder with psychiatric and medical disorders.

BACKGROUND: Prior studies suggest that certain psychiatric and medical disorders co-occur with binge eating disorder (BED). However, there has been no large, community-based study with diagnoses made by clinician interviewers. We used data from that type of study to assess the co-occurrence of various psychiatric and medical disorders with DSM-IV BED and with subthreshold BED. METHOD: From October 2002 to July 2004, we interviewed 150 probands with BED, 150 probands without BED, and 888 of their first-degree relatives (135 of whom had BED, and 54 of whom met specific partial criteria for BED that we defined as subthreshold BED). Study participants were interviewed using the Structured Clinical Interview for DSM-IV to assess BED and other psychiatric disorders and a supplemental structured interview to assess certain medical disorders; participants also completed a self-report questionnaire, the Bad Things Scale. For each psychiatric and medical disorder, we calculated the age- and sex-adjusted co-occurrence odds ratio: the odds of having that disorder in one's lifetime among individuals with (full or subthreshold) lifetime BED compared to individuals without lifetime BED. We also used subjects' responses to the Bad Things Scale to adjust for adversity over-reporting, a type of response bias that could result in spurious findings of co-occurrence. RESULTS: Full BED co-occurred significantly with bipolar disorder, major depressive disorder, bulimia nervosa but not anorexia nervosa, most anxiety disorders, substance use disorders, body dysmorphic disorder, kleptomania, irritable bowel syndrome, and fibromyalgia. These results changed little after correcting for adversity over-reporting. Subthreshold BED co-occurred significantly with many, but not all, of the significantly co-occurring disorders for full BED. CONCLUSION: BED and, to a lesser degree, subthreshold BED exhibit substantial lifetime co-occurrence with psychiatric and medical disorders.

Bulimia symptoms and other risk behaviors during pregnancy in women with bulimia nervosa.

OBJECTIVE: The current study examined the change in bulimic symptoms as well as alcohol, drug, and tobacco use during pregnancy in subjects with bulimia nervosa. METHOD: A self-report questionnaire was used to collect retrospective data on eating disorder symptoms and substance use during pregnancy from 129 participants in a long-term study of bulimia nervosa. Follow-up data were collected for a total of 322 pregnancies occurring over a 10-15-year period. RESULTS: Overall, subjects reported that body dissatisfaction worsened, but binge eating and purging improved during pregnancy. However, the number of women completely abstinent from bulimic symptoms did not change significantly with pregnancy. Body esteem often worsened with pregnancy, particularly for women with active bulimia symptoms. Self-reported alcohol use significantly declined with pregnancy. DISCUSSION: In general, bulimia nervosa symptoms decreased during pregnancy, although the number of women completely abstinent did not change significantly.