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A descriptive analysis of factors contributing to binge eating
Journal of Behavior Therapy and Experimental Psychiatry 30 (1999) 177}189
A descriptive analysis of factors contributing to binge eating Marcella I. Stickney!, Raymond G. Miltenberger",*, Gretchen Wol!" !University of North Dakota, USA "Department of Psychology, North Dakota State University, Fargo, ND 58105, USA
Abstract This study was designed to examine temporally proximal and remote antecedents as well as immediate and delayed consequences of binge eating behavior. Participants included 16 undergraduate females who reported engaging in binge eating at least two times per week and experiencing a sense of lack of control during binge eating episodes on the Questionnaire of Eating and Weight Patterns. Results indicated that the most frequent proximal antecedents to binge eating were negative emotions such as feeling depressed, angry, empty, hopeless, worried, or dissatis"ed. The most frequent consequences of binge eating included relief from negative feelings and thoughts and decrease in hunger or craving. The results of this study suggest that the function of binge eating can be identi"ed through assessment of antecedents and consequences with real time recording and retrospective reports. Treatment implications are discussed. ( 1999 Elsevier Science Ltd. All rights reserved. Keywords: Binge eating; Consequences; Negative emotions
1. Descriptive analysis of binge-eating behavior Binge eating, a primary symptom of binge-eating disorder (BED) and Bulimia Nervosa (BN), is typically de"ned as the consumption of a large amount of food in a short period of time accompanied by a sense of lack of control over eating (American Psychiatric Association, 1994). A signi"cant percentage of women engage in binge
* Corresponding author. Tel.: #701-231-8623; Fax: #701-231-8426. E-mail address: [email protected] (R.G. Miltenberger) 0005-7916/99/$ - see front matter ( 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 1 6 ( 9 9 ) 0 0 0 1 9 - 1
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eating. Schotte and Stunkard (1987) reported that 45% of college-age women reported binge eating at least once per month. Binge eating may result in a number of long-term negative consequences for individuals. Obesity, one possible result for those who binge eat regularly but do not engage in compensatory behaviors, has been linked to a number of serious health conditions including hypertension, diabetes, and cardiovascular disease (Pi-Sunyer, 1991). Compensatory behaviors (e.g., purging and laxative use), an additional problem behavior associated with binge eating, may result in a number of medical complications including dental decay, edema, salivary gland hypertrophy and #uid and electrolyte imbalance (Mitchell, Pomeroy & Adson, 1997). A functional approach to the understanding of binge eating has recently been proposed that attempts to explain binge eating with regard to the immediate antecedents that occasion the behavior and the immediate consequences that reinforce the behavior (Lee & Miltenberger, 1997; Stickney & Miltenberger, 1999). The central assumption underlying this model is that binge eating is maintained by the immediate and automatic reinforcing consequences of the behavior. In other words, when speci"c antecedent conditions are present, the individual engages in binge eating because it provides immediate positively reinforcing or negatively reinforcing consequences for the individual at that time. Assessment of the antecedents associated with binge eating provides useful information regarding potential functions of the behavior because the antecedents increase the motivation for the behavior at particular times or in particular circumstances (e.g., Michael, 1982). Antecedents such as sadness, anger, anxiety, or self-criticism that are rated as intense prior to binge eating may result in conditions under which the binge eating is likely to be more reinforcing than when these antecedents are less intense or absent. For example, when a person is angry and binge foods are available, binge eating may be more likely to occur than when the person is not angry even when binge foods are available at that time. Negative a!ect has been identi"ed as the most frequently reported antecedent of binge eating (Polivy & Herman, 1993). Numerous studies have reported negative a!ect as an antecedent to binge eating and some suggest that a!ect regulation (temporary relief from the negative a!ect) maintains binge eating (e.g., Abraham & Beumont, 1982; Arnow, Kenardy & Agras, 1992; Baucom & Aiken, 1981; Davis, Freeman & Solyom, 1985; Elmore & DeCastro, 1990; Frost, Goolkasian, Ely & Blanchard, 1982; Grilo, Shi!man & Carter-Campbell, 1994; Heatherton & Baumeister, 1991; Johnson & Larson, 1982; Johnson, Schlundt, Barclay, CarrNagle & Engler, 1995; Kenardy, Arnow & Agras, 1996; Lingswiler, Crowther & Stephens, 1988; Loro & Orleans, 1981; Lowe & Fisher, 1983; Ruderman, 1985; Stickney & Miltenberger, 1999). For example, Arnow et al. (1992) examined the precipitants of binge eating for 19 individuals and found negative mood to be an important precipitant. Hsu (1990) assessed 50 bulimic patients regarding their experience during binge eating. Participants reported feeling less depressed during the binge-eating episode. Findings such as these provide preliminary support for the a!ect regulation function of binge eating. However, a limitation of these studies and the many others cited above, is the retrospective reporting of information by respondents rather then self-monitoring at the time of the binge eating.
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Anxiety is also a frequently reported antecedent of binge eating (Abraham & Beumont, 1982; Herman, Polivy, Lank & Heatherton, 1987; Kenardy et al., 1996; Meyer, Waller & Waters, 1998). In addition to identifying anxiety as an antecedent to binge eating, a number of studies have provided preliminary evidence suggesting that binge-eating functions to provide relief from anxiety (Beumont, 1988; Elmore & DeCastro, 1990; Hsu, 1990; Kaye, Gwirtsman, Weiss & Jimerson, 1986; Schlundt & Johnson, 1990). For example, when Kaye et al. (1986) asked the respondents to retrospectively describe their experience during binge eating, a number of participants reported experiencing a reduction in anxiety. Anger at self and at others is another frequently reported antecedent of binge eating (Johnson-Sabine, Wood & Wakeling, 1984; Kenardy et al., 1996; Meyer et al., 1998). Hsu (1990), utilizing retrospective reports, found that approximately 35% of participants reported feeling angry before the binge-eating episode and experiencing a temporary reduction in anger during the "rst part of the binge. In addition to the possibility of providing relief from negative emotions such as sadness, anxiety or anger, a number of researchers have also suggested that binge eating provides relief from self-awareness of self-critical thoughts (Heatherton & Baumeister, 1991). Boredom is yet another frequently reported precipitant of binge eating (Abraham & Beumont, 1982; Meyer et al., 1998; Mitchell, Hatsukami, Eckert & Pyle, 1985; Pyle, Mitchell & Eckert, 1981; Stickney & Miltenberger, 1999). Abraham and Beumont (1982) asked 32 patients who presented with binge eating concerns to retrospectively report precipitants to their binge eating. Fifty nine percent of participants reported experiencing boredom as a precipitant. Momentary relief from boredom may be inferred as a reinforcing consequence of binge eating for those individuals (e.g., Stickney & Miltenberger, 1999). Dietary restraint is also identi"ed in a number of studies as a common antecedent of binge eating (Hawkins & Clement, 1984; Jansen, van den Hout & Griez, 1990; Polivy & Herman, 1985; Ruderman, 1985; Ruderman & Besbeas, 1992). Schlundt, Johnson and Jarrell (1985) found extreme hunger to be predictive of binge eating while moderate levels of hunger were not. It is likely that engaging in dietary restraint results in an increase in the reinforcing quality of foods for the individual. Based on research demonstrating that functional treatments are most successful for other behavior disorders (e.g., Iwata, Pace, Cowdery & Miltenberger, 1994; Kearney & Silverman, 1990; Lee & Miltenberger, 1996; Repp, Felce & Barton, 1988), identifying the function of binge eating for individuals would seem to be essential to maximizing treatment e!ectiveness. Recently, Lee and Miltenberger (1997), Meyer et al. (1998), and Waters, Hill and Waller (1999) suggested that treatments for binge eating in BED and BN individuals must address the antecedents and the consequences in order to maximize the e!ectiveness. Developing treatments based on an individual case formulation rather than generic formulations (Meyer et al., 1998) is important because the necessary components of treatment would logically be expected to di!er depending on the function served by the binge-eating behavior. The purpose of this study was to examine antecedents and consequences for binge eating in college students evidencing symptoms of BN and BED. Developing
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functional treatments depends upon the successful identi"cation of antecedents and consequences functionally related to the problem behaviors. Therefore, we examined temporally remote and contiguous cognitive, a!ective and situational antecedents and consequences of binge eating to identify the variables contributing to binge-eating behavior. In a previous investigation, Stickney and Miltenberger (1999) developed a retrospective self-report rating scale and monitoring forms for assessment of the antecedents and consequences of binge eating. In this investigation, we have expanded the assessment to include an interview and questionnaire to collect descriptive information retrospectively and open-ended questions about antecedents and consequences to be answered at the time of binge eating.
2. Method 2.1. Participants Participants included 16 undergraduate females from a Midwestern university. Participants were selected based on their responses to the Questionnaire of Eating and Weight Patterns (Spitzer et al., 1992) that indicated a frequency of binge eating at least 2 times per week and a sense of lack of control during binge-eating episodes. Nine of the participants were considered to be of normal weight (BMI"20}24), 1 was underweight (BMI(20), 4 were overweight (BMI"25}29), and 2 were obese (BMI"30#). Two participants were taking antidepressant medication during the course of the study. Participants received extra course credit for their participation. 2.2. Measures Conditions associated with binge eating (CABE; Stickney & Miltenberger, 1999). The CABE, a retrospective, self-report measure, consists of 15 items re#ecting emotional or a!ective states. The respondent rates the degree to which each item represents his/her experience prior to, during, and immediately after binge eating on a 5-point scale. Binge eating interview (BEI). The BEI is a semi-structured interview we developed consisting of 32 questions designed to gather information regarding antecedents, consequences, and setting events associated with binge eating as well as information regarding treatment history. Binge eating questionnaire (BEQ). The BEQ is identical to the BEI but is administered as a questionnaire. Binge monitoring forms (Stickney & Miltenberger, 1999). Three-binge monitoring forms, each containing the 15 descriptors included on the CABE, assess the participant's experience immediately before, during, and immediately after binge eating. Description of binge episode (DBE). The DBE is a 5-item self-monitoring form designed to assess the participant's experience immediately before, during, and after binge eating in an open-ended format.
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Antecedent Checklist (AC; Stickney & Miltenberger, 1999). The Antecedent Checklist is a 21-item measure listing environmental events and emotional or physical states, adapted from the Setting Event Checklist (Gardner, Cole, Davidson & Karan, 1986). The respondent is instructed to indicate which of the events occurred during that day prior to the binge eating episode. Acceptability Questionnaire. The Acceptability Questionnaire consists of 7-items (each rated on a 1}7-point scale) designed to assess perceived acceptability of the monitoring methods and experience in the study. 2.3. Procedure Each participant was scheduled for an initial 30-min meeting during which she read and signed the information and consent form. She then completed the BEQ and the CABE. The investigator then completed the BEI with her. She was then provided with instructions on completing the monitoring forms each time she engaged in binge eating and to complete the Antecedent Checklist daily.
3. Results Overall, participants reported 94 binge-eating episodes during the 4 weeks of recording with a mean of 5.88 episodes per individual (range, 0}29) in the 4 weeks or 1.47 episodes per week. In contrast, on the BEQ, participants reported an average frequency of 4.28 binge-eating episodes per week (range, 1}28) prior to initiating self-monitoring. Participants reported the average duration of the binge-eating episode to be 1 h (range, 15 min}3.5 h). On an average, participants rated the degree to which they experienced a lack of control during eating (on a 7-point Likert scale) to be 5.25 (range, 3}7). Participants reported that they were most likely to binge eat in the evening (n"8) and least likely to binge eat in the morning (n"15). Thirteen participants reported that they were most likely to binge eat in their dorm room/home; while two participants indicated that they were likely to binge eat in their car. Consistent with previous literature, most participants binge ate alone (n"11). Surprisingly, "ve participants reported binge eating in the presence of others. In response to the question `Does anything else bring the same sense of satisfaction or relief as binge eating?a three participants reported no, six reported exercise, three identi"ed being with others, three identi"ed purging, two reported driving; while each of the following was identi"ed once; restraint, crocheting, playing with pets, successfully completing a task, journaling, and relaxation. As reported on the BEQ, the mean duration of the binge-eating pattern was 6.01 yr (range, 1.2}18 yr). The mean onset was 13.6 yr of age with a median of 15 yr of age (range, 4}17). Seven participants reported that they had sought treatment for their eating patterns in the past. Of those participants, four reported that they did not "nd the treatment to be helpful; three participants considered the treatment to be at least somewhat helpful.
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The most frequently reported antecedents on the BEQ and BEI (in response to open-ended questions) were: feeling depressed, upset, empty, hopeless, stressed and overwhelmed (see Table 1). In contrast, the most frequently reported antecedents to binge eating on the retrospective questionnaire (CABE) were dissatisfaction with body weight/shape, boredom, worry about responsibilities, focus on food, feeling down/sad, worry about problems and frustration (see Table 2). Similarly, on the monitoring forms, respondents reported dissatisfaction with body weight/shape, boredom, worry about responsibilities, and focus on food as the most frequent proximal antecedents to binge eating (see Table 3). Remote antecedents (i.e., antecedents occurring within 24 h prior to the binge) which were more likely to be reported on binge days than on non-binge days were: availability of desirable (binge) foods, alone for a long period of time during the day, felt down/sad, felt unusually tired/fatigued, consumed more food than one wanted to, deprived of/limited food intake in the previous 12}24 h, felt agitated/irritable, "ght, argument, or other negative interaction, consumed alcohol today, and more hurried/rushed than usual (see Table 6). On both the BEI and BEQ, participants described their experience during the binge as: feeling better, relieved, good, content, and focused on eating (see Table 1). Overall, on the CABE, all items, excluding dissatisfaction with body weight/shape, focus on food/eating, and feeling guilty, decreased in intensity from prior to the binge Table 1 Most frequent responses to the BEQ and BEI Item
Response category
Are there particular situations which tend to trigger binge eating for you or cause you to want to binge?
Depressed, upset, empty, hopeless; stressed, overwhelmed; negative interaction; boredom; being alone
Are there particular feelings, thoughts or emotions which tend to trigger a binge or which cause you to want to binge?
Depressed, upset, empty, hopeless; stressed, overwhelmed; lonely; anger; anxious
Are there particular feelings, thoughts, or emotions which never trigger a binge or cause you to want to binge?
Happiness, contentment, calmness, feeling wanted; feeling energetic, ambitious; being with others
What is going on with you before you binge? (feelings, thoughts, emotions)
Depressed, upset, empty, hopeless; lonely; boredom; feel loss of control in life
What is going on with you while you are binge eating? (How does it contrast with before the binge?)
Feeling better, relieved, good, content; focused on eating
What is going on with you immediately after you binge? (How does it contrast with before and during the binge?)
Feeling guilty, ashamed; feeling ill, after fullness; anger
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Table 2 Mean ratings across participants on the conditions associated with binge-eating scale (CABE) Item
Before
During
After
Anxious/nervous Bored Angry at self Angry at other Dissatis"ed with body shape/weight Worrying about responsibilities about problems about the future Physically hungry Lonely Frustrated Down/sad Focused on food Feel guilty Agitated or irritable
2.81 3.69 2.81 2.38 3.75
2.50 2.13 2.63 2.00 3.44
2.19 2.63 4.50 2.06 4.81
3.69 3.31 2.75 2.88 3.06 3.13 3.44 3.50 2.38 2.75
2.25 2.31 2.00 1.81 2.44 2.44 2.50 3.69 3.13 2.25
3.00 2.81 2.63 1.13 3.13 3.25 3.31 2.81 4.75 2.44
Note: The intensity of each item was rated on a 1 (not at all)}5 (extremely) point scale.
Table 3 Mean ratings across participants on the binge-monitoring forms Item
Before
During
After
Anxious/nervous Bored Angry at self Angry at other Dissatis"ed with body shape/weight Worrying about responsibilities about problems about the future Physically hungry Lonely Frustrated Down/sad Focused on food Feel guilty Agitated or irritable
2.09 3.10 2.28 2.08 3.17
2.48 2.10 2.92 2.23 3.23
2.29 2.02 3.37 1.80 4.19
2.89 2.79 2.52 2.36 2.69 2.49 2.44 2.80 1.96 2.32
2.34 2.40 2.27 1.57 2.56 3.27 2.47 3.51 3.08 2.50
2.59 2.67 2.68 1.15 2.47 2.82 2.83 1.86 3.67 2.60
Note: In the `Beforea and `Aftera time periods, the intensity of each item was rated on a 1 (not at all)}5 (extremely) point scale. In the `Duringa time period, a di!erent scale was used: 1"much less intense, 2"less intense, 3"same intensity, 4"more intense, 5"much more intense. Therefore, scores less than 3 suggest that the intensity of the item rated, decreased from before to during binge eating.
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to during. For those antecedents that decreased from prior to during binge eating, results indicated an increase in those negative states from during to after binge-eating suggesting that the positive e!ects of the binge were quite brief (see Table 2). Similar to the CABE, on the monitoring forms, individuals reported a decrease in all negative states during binge eating, except dissatisfaction with body weight/shape, focus on food/eating, frustration, and feeling guilty. Responses to the monitoring forms indicate a decrease from prior to after the binge episode on 7 of the variables and an increase on 8 of the variables (see Table 3). Answers to open-ended questions about the participants' experience during binge eating are reported in Table 4 as functions of binge eating. Escape from negative feelings and thoughts was identi"ed as a function for 45 and 29% of binge eating episodes, respectively. Relief from hunger/craving was identi"ed as a function of binge eating for 16% of binge-eating episodes. Based on participants' responses to the monitoring rating scale, relief from boredom, hunger, worry and loneliness were the most frequent functions of binge-eating behavior (see Table 5). Functions were identi"ed when items were rated as 3 or higher prior to a binge with a reported decrease during binge eating. Relief from negative feelings was the most frequently reported function of bingeeating on both the closed- and open-ended monitoring forms. Relief from negative thoughts (e.g., worry) was the second most-commonly experienced function of bingeeating on both the closed- and open-ended monitoring forms. Relief from hunger was reported as a function of 45% of the binge-eating episodes on the closed-ended monitoring forms (see Table 5). Responses to the Acceptability Questionnaire indicated that participants considered completing the monitoring to be relatively easy (M"5.36) although somewhat disruptive (M"3.43) and somewhat time consuming (M"2.93). Importantly, participants considered the monitoring to be quite helpful in improving their understanding of their binge-eating behavior (M"5.36), and their experience in the study to be quite positive (M"5.36). Participants reported that they were not more likely to seek help for their eating patterns after participating in the study. Table 4 Functions of binge eating as described on the open ended monitoring form Function
n
%
Relief from negative feelings Relief from negative thoughts Relief from hunger Relief from cravings Social binge Reward self Function unclear
42 23 7 8 1 2 11
45 29 7 9 1 2 12
Note: Numbers re#ect percentage of binges for which the function was identi"ed.
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Table 5 Functions of binge eating based on responses to the monitoring form Item
n
%
Anxious/nervous Bored Angry at self Angry at other Dissatis"ed with body shape/weight Worrying about responsibilities about problems about the future Physically hungry Lonely Frustrated Down/sad Focused on food Feel guilty Agitated or irritable
11 47 11 15 23
12 50 12 16 24
30 27 32 42 24 13 15 2 1 17
32 29 34 45 26 14 16 2 1 18
Note: n refers to the number of times that item was a function of a bingeeating episode. % refers to the % of binge-eating episodes for which that item was a function. Function was de"ned as having been rated as greater than or equal to 3 prior to the binge and less than 3 (a reported decrease in intensity) during the binge.
4. Discussion This study provides converging data from real time assessments (monitoring forms and antecedent checklist) and retrospective assessments (interview, questionnaire and rating scale) regarding the antecedents and consequences of binge eating. A variety of proximal and remote antecedents were identi"ed, primarily negative emotional, cognitive and environmental events, hunger and boredom, that provided the motivation for binge eating. Binge eating then served a negative reinforcement function in many cases by providing relief from these aversive antecedent conditions. Although the information from the various assessment methods was not identical for each participant, the major categories of the antecedents and consequences were consistent across methods, thus providing a modicum of validation for both methods. A strength of this investigation is the consistency of the data on the antecedents and consequences across the di!erent real-time and retrospective measures. Although real-time recording at the time of the binge-eating episode is the preferred assessment method because it reduces biases associated with reporting on past events, both the methods have their merits. Real-time recording allows the individual to observe and record her cognitive and emotional experiences at the time of binge eating before they decay over time. However, monitoring at the time of the binge-eating episode is time consuming and may be resisted by individuals for various reasons (i.e., it interferes with the binge-eating process, it requires the individuals to record painful events that
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Table 6 Percentage of time each item was endorsed on the antecedent checklist Item
Non-binge day
Binge day
p B/A
Informed of something disappointing Received negative feedback Refused an object/activity I requested Evaluated Fight, argument or other negative interaction Disciplined or reprimanded Hurried/rushed more than usual Did not sleep well last night Changes in my living environment Expected visitors (family/friends) Expected visitors who did not arrive Had visitors Felt unusually tired/fatigued Felt agitated/irritable Felt down/sad Felt ill Limited food intake over previous 12}24 hrs Desirable (binge) foods were available Alone for a long period of time during the day Consumed alcohol today Consumed more food than I wanted to
16 12 5 15 13 3 22 29 7 9 3 24 26 15 18 14 7 20 3 14 13
19 18 5 15 22 5 29 40 13 11 6 24 45 29 41 18 23 74 33 22 31
0.54 0.60 0.50 0.50 0.63 0.63 0.57 0.58 0.65 0.55 0.67 0.50 0.63 0.66 0.69 0.56 0.77 0.79 0.92 0.61 0.70
Note: p B/A re#ects the probability of the occurrence of a binge given the occurrence of the antecedent.
they are trying to ignore or supplant, it may draw attention to the individual if others are present). Therefore, retrospective reporting o!ers a valuable complement to real-time monitoring. Retrospective reporting is easier and more convenient to carry out than real-time recording because it does not require data collection at the time of the binge-eating episode. As long as researchers understand the limitations of retrospective reporting, the information may be a valuable adjunct to that gathered at the time of the binge-eating episode. This investigation enhances our understanding of binge eating by pointing to the operant functions that the behavior may serve for individuals. Identi"cation of antecedent conditions that are generally aversive to the individual with subsequent changes in these conditions during binge eating suggests that binge eating is maintained by negative reinforcement. The negative reinforcement function identi"ed in this investigation is consistent with the results of other investigations that suggest that binge eating brings momentary relief from aversive conditions such as depressed mood, anxiety and anger (e.g., Abraham & Beumont, 1982; Kenardy et al., 1996; Schlundt & Johnson, 1990). The strength of this investigation relative to many previous investigations is the demonstration of these functions with real-time recording. It is clear from this study as well as previous studies that binge eating serves functions that di!er across individuals. It is important to note that binge eating is
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likely to be most e!ectively treated utilizing interventions speci"c to the identi"ed function (Lee & Miltenberger, 1997; Waters et al., 1999). Therefore, it is necessary for clinicians to assess the function of binge eating for each individual in order to develop the most e!ective intervention. The methods utilized in this study provide an example of relatively e$cient assessment techniques to identify the function of binge eating for individuals. A limitation of this study is that the sample consisted of a relatively small number of college students. Therefore, these "ndings may have limited generalizability to other individuals who engage in binge eating. In addition, the small sample-size did not permit comparisons between participants with symptoms of bulimia nervosa versus binge eating disorder. Replication of the study with a clinical population of individuals with bulimia nervosa and binge eating disorder is warranted. The second limitation of the study is that we have no evidence that the participants recorded the antecedents and consequences of binge eating at the time binge eating occurred as instructed, even though all participants reported that they did. Future research using hand-held computers or electronic recorders for data collection would enable researchers to pinpoint the exact time that recording took place. The use of such equipment would help insure the integrity of the assessment. However, even with such equipment, we could not be certain that recording took place at the time that binge eating occurred, because there is no independent veri"cation of the time of binge eating. One possible solution to this problem is to have participants record at intervals, throughout the day, when signaled by the electronic data device. A record of mood, cognitions, interpersonal events and other possible antecedents throughout the day would allow researchers to track these events and investigate their relationship to binge eating. Such signaled interval recording would be a useful adjunct to event-related recording at the time of binge eating. Future research should also seek to more clearly delineate the function of binge eating for individual participants so that the most relevant treatment can be delivered. For example, treatment would be di!erent for an individual whose binge eating brings relief from depressed mood than for an individual whose binge eating resulted in relief from anxiety. Although the binge eating for both individuals is negatively reinforced by reduction in an aversive condition, treatments for the two individuals would di!er; one focusing on alleviating depression and the other on anxiety-reduction. One "nal avenue for future research is the demonstration that functional treatments for binge eating are most e!ective. If treatments based on functional assessment results are more e!ective than generic treatments, then the validity of functional assessment is enhanced. Although it makes sense that functional treatments would be most e!ective based on the results of treatment for other behavior disorders (Iwata et al., 1994; Kearney & Silverman, 1990), the relative e$cacy of functional treatments for binge eating has yet to be established. References Abraham, S. F., & Beumont, P. J. V. (1982). How patients describe bulimia or binge eating. Psychological Medicine, 12, 625}635.
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Lowe, M. R., & Fisher, E. B. (1983). Emotional reactivity, emotional eating and obesity: A naturalistic study. Journal of Behavioral Medicine, 6, 135}149. Meyer, C., Waller, G., & Waters, A. (1998). Emotional states and bulimic psychopathology. In H. Hoek, J. Treasure, & M. Katzman, Neurobiology in the Treatment of Eating Disorders (pp. 263}279). New York: Wiley. Michael, J. (1982). Distinguishing between the discriminative and motivational functions of stimuli. Journal of the Experimental Analysis of Behavior, 37, 149}155. Mitchell, J. E., Hatsukami, D., Eckert, E., & Pyle, R. L. (1985). Characteristics of 275 patients with bulimia. American Journal of Psychiatry, 142, 482}485. Mitchell, J. E., Pomeroy, C., & Adson, D. E. (1997). Managing medical complications. In D. M. Garner, & P. E. Gar"nkel, Handbook of treatment for eating disorders (2nd ed.) (pp. 383}393). New York: Guilford Press. Pi-Sunyer, F. X. (1991). Health implications of obesity. American Journal of Clinical Nutrition, 53, 1595S}1603S. Polivy, J., & Herman, C. P. (1985). Dieting and bingeing: A causal analysis. American Psychologist, 50, 193}201. Polivy, J., & Herman, C. P. (1993). Etiology of binge eating: Psychological mechanisms. In C. G. Fairburn, & G. T. Wilson, Binge eating: Nature, assessment and treatment (pp. 173}205). New York: Guilford Press. Pyle, R. L., Mitchell, J. E., & Eckert, E. D. (1981). Bulimia: A report of 34 cases. Journal of Clinical Psychiatry, 42, 60}64. Repp, A., Felce, D., & Barton, L. (1988). Basing treatment of stereotypic and self-injurious behavior on hypotheses of their causes. Journal of Applied Behavior Analysis, 21, 281}289. Ruderman, A. J. (1985). Dysphoric mood and overeating. Journal of Abnormal Psychology, 94, 78}85. Ruderman, A. J., & Besbeas, M. (1992). Psychological characteristics of dieters and bulimics. Journal of Abnormal Psychology, 101, 383}390. Schlundt, D. G., & Johnson, W. G. (1990). Eating disorders: Assessment and treatment. Boston: Allyn and Bacon. Schlundt, D. G., Johnson, W. G., & Jarrell, M. P. (1985). A naturalistic functional analysis of eating behavior in bulimia and obesity. Advances in Behavior Research and Therapy, 7, 149}162. Schotte, D. E., & Stunkard, A. J. (1987). Bulimia vs. bulimic behaviors on a college campus. Journal of American Medical Association, 258, 1213}1215. Spitzer, R. L., Devlin, M., Walsh, B. T., Hasin, D., Wing, R., Marcus, M., Stunkard, A., Wadden, T., Yanovski, S., Agras, S., Mitchell, J., & Nonas, C. (1992). Binge eating disorder: A multisite "eld trial of the diagnostic criteria. Internal Journal of Eating Disorders, 11, 191}203. Stickney, M. I., & Miltenberger, R. G. (1999). Evaluating direct and indirect measures for the functional assessment of binge eating. International Journal of Eating Disorders, 26, 195}204. Waters, A., Hill, A., & Waller, G. (1999). Bulimics' responses to food cravings: Is binge eating a product of hunger or emotional state? International Journal of Eating Disorders, in press.
A descriptive analysis of factors contributing to binge eating Marcella I. Stickney!, Raymond G. Miltenberger",*, Gretchen Wol!" !University of North Dakota, USA "Department of Psychology, North Dakota State University, Fargo, ND 58105, USA
Abstract This study was designed to examine temporally proximal and remote antecedents as well as immediate and delayed consequences of binge eating behavior. Participants included 16 undergraduate females who reported engaging in binge eating at least two times per week and experiencing a sense of lack of control during binge eating episodes on the Questionnaire of Eating and Weight Patterns. Results indicated that the most frequent proximal antecedents to binge eating were negative emotions such as feeling depressed, angry, empty, hopeless, worried, or dissatis"ed. The most frequent consequences of binge eating included relief from negative feelings and thoughts and decrease in hunger or craving. The results of this study suggest that the function of binge eating can be identi"ed through assessment of antecedents and consequences with real time recording and retrospective reports. Treatment implications are discussed. ( 1999 Elsevier Science Ltd. All rights reserved. Keywords: Binge eating; Consequences; Negative emotions
1. Descriptive analysis of binge-eating behavior Binge eating, a primary symptom of binge-eating disorder (BED) and Bulimia Nervosa (BN), is typically de"ned as the consumption of a large amount of food in a short period of time accompanied by a sense of lack of control over eating (American Psychiatric Association, 1994). A signi"cant percentage of women engage in binge
* Corresponding author. Tel.: #701-231-8623; Fax: #701-231-8426. E-mail address: [email protected] (R.G. Miltenberger) 0005-7916/99/$ - see front matter ( 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 1 6 ( 9 9 ) 0 0 0 1 9 - 1
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eating. Schotte and Stunkard (1987) reported that 45% of college-age women reported binge eating at least once per month. Binge eating may result in a number of long-term negative consequences for individuals. Obesity, one possible result for those who binge eat regularly but do not engage in compensatory behaviors, has been linked to a number of serious health conditions including hypertension, diabetes, and cardiovascular disease (Pi-Sunyer, 1991). Compensatory behaviors (e.g., purging and laxative use), an additional problem behavior associated with binge eating, may result in a number of medical complications including dental decay, edema, salivary gland hypertrophy and #uid and electrolyte imbalance (Mitchell, Pomeroy & Adson, 1997). A functional approach to the understanding of binge eating has recently been proposed that attempts to explain binge eating with regard to the immediate antecedents that occasion the behavior and the immediate consequences that reinforce the behavior (Lee & Miltenberger, 1997; Stickney & Miltenberger, 1999). The central assumption underlying this model is that binge eating is maintained by the immediate and automatic reinforcing consequences of the behavior. In other words, when speci"c antecedent conditions are present, the individual engages in binge eating because it provides immediate positively reinforcing or negatively reinforcing consequences for the individual at that time. Assessment of the antecedents associated with binge eating provides useful information regarding potential functions of the behavior because the antecedents increase the motivation for the behavior at particular times or in particular circumstances (e.g., Michael, 1982). Antecedents such as sadness, anger, anxiety, or self-criticism that are rated as intense prior to binge eating may result in conditions under which the binge eating is likely to be more reinforcing than when these antecedents are less intense or absent. For example, when a person is angry and binge foods are available, binge eating may be more likely to occur than when the person is not angry even when binge foods are available at that time. Negative a!ect has been identi"ed as the most frequently reported antecedent of binge eating (Polivy & Herman, 1993). Numerous studies have reported negative a!ect as an antecedent to binge eating and some suggest that a!ect regulation (temporary relief from the negative a!ect) maintains binge eating (e.g., Abraham & Beumont, 1982; Arnow, Kenardy & Agras, 1992; Baucom & Aiken, 1981; Davis, Freeman & Solyom, 1985; Elmore & DeCastro, 1990; Frost, Goolkasian, Ely & Blanchard, 1982; Grilo, Shi!man & Carter-Campbell, 1994; Heatherton & Baumeister, 1991; Johnson & Larson, 1982; Johnson, Schlundt, Barclay, CarrNagle & Engler, 1995; Kenardy, Arnow & Agras, 1996; Lingswiler, Crowther & Stephens, 1988; Loro & Orleans, 1981; Lowe & Fisher, 1983; Ruderman, 1985; Stickney & Miltenberger, 1999). For example, Arnow et al. (1992) examined the precipitants of binge eating for 19 individuals and found negative mood to be an important precipitant. Hsu (1990) assessed 50 bulimic patients regarding their experience during binge eating. Participants reported feeling less depressed during the binge-eating episode. Findings such as these provide preliminary support for the a!ect regulation function of binge eating. However, a limitation of these studies and the many others cited above, is the retrospective reporting of information by respondents rather then self-monitoring at the time of the binge eating.
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Anxiety is also a frequently reported antecedent of binge eating (Abraham & Beumont, 1982; Herman, Polivy, Lank & Heatherton, 1987; Kenardy et al., 1996; Meyer, Waller & Waters, 1998). In addition to identifying anxiety as an antecedent to binge eating, a number of studies have provided preliminary evidence suggesting that binge-eating functions to provide relief from anxiety (Beumont, 1988; Elmore & DeCastro, 1990; Hsu, 1990; Kaye, Gwirtsman, Weiss & Jimerson, 1986; Schlundt & Johnson, 1990). For example, when Kaye et al. (1986) asked the respondents to retrospectively describe their experience during binge eating, a number of participants reported experiencing a reduction in anxiety. Anger at self and at others is another frequently reported antecedent of binge eating (Johnson-Sabine, Wood & Wakeling, 1984; Kenardy et al., 1996; Meyer et al., 1998). Hsu (1990), utilizing retrospective reports, found that approximately 35% of participants reported feeling angry before the binge-eating episode and experiencing a temporary reduction in anger during the "rst part of the binge. In addition to the possibility of providing relief from negative emotions such as sadness, anxiety or anger, a number of researchers have also suggested that binge eating provides relief from self-awareness of self-critical thoughts (Heatherton & Baumeister, 1991). Boredom is yet another frequently reported precipitant of binge eating (Abraham & Beumont, 1982; Meyer et al., 1998; Mitchell, Hatsukami, Eckert & Pyle, 1985; Pyle, Mitchell & Eckert, 1981; Stickney & Miltenberger, 1999). Abraham and Beumont (1982) asked 32 patients who presented with binge eating concerns to retrospectively report precipitants to their binge eating. Fifty nine percent of participants reported experiencing boredom as a precipitant. Momentary relief from boredom may be inferred as a reinforcing consequence of binge eating for those individuals (e.g., Stickney & Miltenberger, 1999). Dietary restraint is also identi"ed in a number of studies as a common antecedent of binge eating (Hawkins & Clement, 1984; Jansen, van den Hout & Griez, 1990; Polivy & Herman, 1985; Ruderman, 1985; Ruderman & Besbeas, 1992). Schlundt, Johnson and Jarrell (1985) found extreme hunger to be predictive of binge eating while moderate levels of hunger were not. It is likely that engaging in dietary restraint results in an increase in the reinforcing quality of foods for the individual. Based on research demonstrating that functional treatments are most successful for other behavior disorders (e.g., Iwata, Pace, Cowdery & Miltenberger, 1994; Kearney & Silverman, 1990; Lee & Miltenberger, 1996; Repp, Felce & Barton, 1988), identifying the function of binge eating for individuals would seem to be essential to maximizing treatment e!ectiveness. Recently, Lee and Miltenberger (1997), Meyer et al. (1998), and Waters, Hill and Waller (1999) suggested that treatments for binge eating in BED and BN individuals must address the antecedents and the consequences in order to maximize the e!ectiveness. Developing treatments based on an individual case formulation rather than generic formulations (Meyer et al., 1998) is important because the necessary components of treatment would logically be expected to di!er depending on the function served by the binge-eating behavior. The purpose of this study was to examine antecedents and consequences for binge eating in college students evidencing symptoms of BN and BED. Developing
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functional treatments depends upon the successful identi"cation of antecedents and consequences functionally related to the problem behaviors. Therefore, we examined temporally remote and contiguous cognitive, a!ective and situational antecedents and consequences of binge eating to identify the variables contributing to binge-eating behavior. In a previous investigation, Stickney and Miltenberger (1999) developed a retrospective self-report rating scale and monitoring forms for assessment of the antecedents and consequences of binge eating. In this investigation, we have expanded the assessment to include an interview and questionnaire to collect descriptive information retrospectively and open-ended questions about antecedents and consequences to be answered at the time of binge eating.
2. Method 2.1. Participants Participants included 16 undergraduate females from a Midwestern university. Participants were selected based on their responses to the Questionnaire of Eating and Weight Patterns (Spitzer et al., 1992) that indicated a frequency of binge eating at least 2 times per week and a sense of lack of control during binge-eating episodes. Nine of the participants were considered to be of normal weight (BMI"20}24), 1 was underweight (BMI(20), 4 were overweight (BMI"25}29), and 2 were obese (BMI"30#). Two participants were taking antidepressant medication during the course of the study. Participants received extra course credit for their participation. 2.2. Measures Conditions associated with binge eating (CABE; Stickney & Miltenberger, 1999). The CABE, a retrospective, self-report measure, consists of 15 items re#ecting emotional or a!ective states. The respondent rates the degree to which each item represents his/her experience prior to, during, and immediately after binge eating on a 5-point scale. Binge eating interview (BEI). The BEI is a semi-structured interview we developed consisting of 32 questions designed to gather information regarding antecedents, consequences, and setting events associated with binge eating as well as information regarding treatment history. Binge eating questionnaire (BEQ). The BEQ is identical to the BEI but is administered as a questionnaire. Binge monitoring forms (Stickney & Miltenberger, 1999). Three-binge monitoring forms, each containing the 15 descriptors included on the CABE, assess the participant's experience immediately before, during, and immediately after binge eating. Description of binge episode (DBE). The DBE is a 5-item self-monitoring form designed to assess the participant's experience immediately before, during, and after binge eating in an open-ended format.
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Antecedent Checklist (AC; Stickney & Miltenberger, 1999). The Antecedent Checklist is a 21-item measure listing environmental events and emotional or physical states, adapted from the Setting Event Checklist (Gardner, Cole, Davidson & Karan, 1986). The respondent is instructed to indicate which of the events occurred during that day prior to the binge eating episode. Acceptability Questionnaire. The Acceptability Questionnaire consists of 7-items (each rated on a 1}7-point scale) designed to assess perceived acceptability of the monitoring methods and experience in the study. 2.3. Procedure Each participant was scheduled for an initial 30-min meeting during which she read and signed the information and consent form. She then completed the BEQ and the CABE. The investigator then completed the BEI with her. She was then provided with instructions on completing the monitoring forms each time she engaged in binge eating and to complete the Antecedent Checklist daily.
3. Results Overall, participants reported 94 binge-eating episodes during the 4 weeks of recording with a mean of 5.88 episodes per individual (range, 0}29) in the 4 weeks or 1.47 episodes per week. In contrast, on the BEQ, participants reported an average frequency of 4.28 binge-eating episodes per week (range, 1}28) prior to initiating self-monitoring. Participants reported the average duration of the binge-eating episode to be 1 h (range, 15 min}3.5 h). On an average, participants rated the degree to which they experienced a lack of control during eating (on a 7-point Likert scale) to be 5.25 (range, 3}7). Participants reported that they were most likely to binge eat in the evening (n"8) and least likely to binge eat in the morning (n"15). Thirteen participants reported that they were most likely to binge eat in their dorm room/home; while two participants indicated that they were likely to binge eat in their car. Consistent with previous literature, most participants binge ate alone (n"11). Surprisingly, "ve participants reported binge eating in the presence of others. In response to the question `Does anything else bring the same sense of satisfaction or relief as binge eating?a three participants reported no, six reported exercise, three identi"ed being with others, three identi"ed purging, two reported driving; while each of the following was identi"ed once; restraint, crocheting, playing with pets, successfully completing a task, journaling, and relaxation. As reported on the BEQ, the mean duration of the binge-eating pattern was 6.01 yr (range, 1.2}18 yr). The mean onset was 13.6 yr of age with a median of 15 yr of age (range, 4}17). Seven participants reported that they had sought treatment for their eating patterns in the past. Of those participants, four reported that they did not "nd the treatment to be helpful; three participants considered the treatment to be at least somewhat helpful.
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The most frequently reported antecedents on the BEQ and BEI (in response to open-ended questions) were: feeling depressed, upset, empty, hopeless, stressed and overwhelmed (see Table 1). In contrast, the most frequently reported antecedents to binge eating on the retrospective questionnaire (CABE) were dissatisfaction with body weight/shape, boredom, worry about responsibilities, focus on food, feeling down/sad, worry about problems and frustration (see Table 2). Similarly, on the monitoring forms, respondents reported dissatisfaction with body weight/shape, boredom, worry about responsibilities, and focus on food as the most frequent proximal antecedents to binge eating (see Table 3). Remote antecedents (i.e., antecedents occurring within 24 h prior to the binge) which were more likely to be reported on binge days than on non-binge days were: availability of desirable (binge) foods, alone for a long period of time during the day, felt down/sad, felt unusually tired/fatigued, consumed more food than one wanted to, deprived of/limited food intake in the previous 12}24 h, felt agitated/irritable, "ght, argument, or other negative interaction, consumed alcohol today, and more hurried/rushed than usual (see Table 6). On both the BEI and BEQ, participants described their experience during the binge as: feeling better, relieved, good, content, and focused on eating (see Table 1). Overall, on the CABE, all items, excluding dissatisfaction with body weight/shape, focus on food/eating, and feeling guilty, decreased in intensity from prior to the binge Table 1 Most frequent responses to the BEQ and BEI Item
Response category
Are there particular situations which tend to trigger binge eating for you or cause you to want to binge?
Depressed, upset, empty, hopeless; stressed, overwhelmed; negative interaction; boredom; being alone
Are there particular feelings, thoughts or emotions which tend to trigger a binge or which cause you to want to binge?
Depressed, upset, empty, hopeless; stressed, overwhelmed; lonely; anger; anxious
Are there particular feelings, thoughts, or emotions which never trigger a binge or cause you to want to binge?
Happiness, contentment, calmness, feeling wanted; feeling energetic, ambitious; being with others
What is going on with you before you binge? (feelings, thoughts, emotions)
Depressed, upset, empty, hopeless; lonely; boredom; feel loss of control in life
What is going on with you while you are binge eating? (How does it contrast with before the binge?)
Feeling better, relieved, good, content; focused on eating
What is going on with you immediately after you binge? (How does it contrast with before and during the binge?)
Feeling guilty, ashamed; feeling ill, after fullness; anger
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Table 2 Mean ratings across participants on the conditions associated with binge-eating scale (CABE) Item
Before
During
After
Anxious/nervous Bored Angry at self Angry at other Dissatis"ed with body shape/weight Worrying about responsibilities about problems about the future Physically hungry Lonely Frustrated Down/sad Focused on food Feel guilty Agitated or irritable
2.81 3.69 2.81 2.38 3.75
2.50 2.13 2.63 2.00 3.44
2.19 2.63 4.50 2.06 4.81
3.69 3.31 2.75 2.88 3.06 3.13 3.44 3.50 2.38 2.75
2.25 2.31 2.00 1.81 2.44 2.44 2.50 3.69 3.13 2.25
3.00 2.81 2.63 1.13 3.13 3.25 3.31 2.81 4.75 2.44
Note: The intensity of each item was rated on a 1 (not at all)}5 (extremely) point scale.
Table 3 Mean ratings across participants on the binge-monitoring forms Item
Before
During
After
Anxious/nervous Bored Angry at self Angry at other Dissatis"ed with body shape/weight Worrying about responsibilities about problems about the future Physically hungry Lonely Frustrated Down/sad Focused on food Feel guilty Agitated or irritable
2.09 3.10 2.28 2.08 3.17
2.48 2.10 2.92 2.23 3.23
2.29 2.02 3.37 1.80 4.19
2.89 2.79 2.52 2.36 2.69 2.49 2.44 2.80 1.96 2.32
2.34 2.40 2.27 1.57 2.56 3.27 2.47 3.51 3.08 2.50
2.59 2.67 2.68 1.15 2.47 2.82 2.83 1.86 3.67 2.60
Note: In the `Beforea and `Aftera time periods, the intensity of each item was rated on a 1 (not at all)}5 (extremely) point scale. In the `Duringa time period, a di!erent scale was used: 1"much less intense, 2"less intense, 3"same intensity, 4"more intense, 5"much more intense. Therefore, scores less than 3 suggest that the intensity of the item rated, decreased from before to during binge eating.
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to during. For those antecedents that decreased from prior to during binge eating, results indicated an increase in those negative states from during to after binge-eating suggesting that the positive e!ects of the binge were quite brief (see Table 2). Similar to the CABE, on the monitoring forms, individuals reported a decrease in all negative states during binge eating, except dissatisfaction with body weight/shape, focus on food/eating, frustration, and feeling guilty. Responses to the monitoring forms indicate a decrease from prior to after the binge episode on 7 of the variables and an increase on 8 of the variables (see Table 3). Answers to open-ended questions about the participants' experience during binge eating are reported in Table 4 as functions of binge eating. Escape from negative feelings and thoughts was identi"ed as a function for 45 and 29% of binge eating episodes, respectively. Relief from hunger/craving was identi"ed as a function of binge eating for 16% of binge-eating episodes. Based on participants' responses to the monitoring rating scale, relief from boredom, hunger, worry and loneliness were the most frequent functions of binge-eating behavior (see Table 5). Functions were identi"ed when items were rated as 3 or higher prior to a binge with a reported decrease during binge eating. Relief from negative feelings was the most frequently reported function of bingeeating on both the closed- and open-ended monitoring forms. Relief from negative thoughts (e.g., worry) was the second most-commonly experienced function of bingeeating on both the closed- and open-ended monitoring forms. Relief from hunger was reported as a function of 45% of the binge-eating episodes on the closed-ended monitoring forms (see Table 5). Responses to the Acceptability Questionnaire indicated that participants considered completing the monitoring to be relatively easy (M"5.36) although somewhat disruptive (M"3.43) and somewhat time consuming (M"2.93). Importantly, participants considered the monitoring to be quite helpful in improving their understanding of their binge-eating behavior (M"5.36), and their experience in the study to be quite positive (M"5.36). Participants reported that they were not more likely to seek help for their eating patterns after participating in the study. Table 4 Functions of binge eating as described on the open ended monitoring form Function
n
%
Relief from negative feelings Relief from negative thoughts Relief from hunger Relief from cravings Social binge Reward self Function unclear
42 23 7 8 1 2 11
45 29 7 9 1 2 12
Note: Numbers re#ect percentage of binges for which the function was identi"ed.
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Table 5 Functions of binge eating based on responses to the monitoring form Item
n
%
Anxious/nervous Bored Angry at self Angry at other Dissatis"ed with body shape/weight Worrying about responsibilities about problems about the future Physically hungry Lonely Frustrated Down/sad Focused on food Feel guilty Agitated or irritable
11 47 11 15 23
12 50 12 16 24
30 27 32 42 24 13 15 2 1 17
32 29 34 45 26 14 16 2 1 18
Note: n refers to the number of times that item was a function of a bingeeating episode. % refers to the % of binge-eating episodes for which that item was a function. Function was de"ned as having been rated as greater than or equal to 3 prior to the binge and less than 3 (a reported decrease in intensity) during the binge.
4. Discussion This study provides converging data from real time assessments (monitoring forms and antecedent checklist) and retrospective assessments (interview, questionnaire and rating scale) regarding the antecedents and consequences of binge eating. A variety of proximal and remote antecedents were identi"ed, primarily negative emotional, cognitive and environmental events, hunger and boredom, that provided the motivation for binge eating. Binge eating then served a negative reinforcement function in many cases by providing relief from these aversive antecedent conditions. Although the information from the various assessment methods was not identical for each participant, the major categories of the antecedents and consequences were consistent across methods, thus providing a modicum of validation for both methods. A strength of this investigation is the consistency of the data on the antecedents and consequences across the di!erent real-time and retrospective measures. Although real-time recording at the time of the binge-eating episode is the preferred assessment method because it reduces biases associated with reporting on past events, both the methods have their merits. Real-time recording allows the individual to observe and record her cognitive and emotional experiences at the time of binge eating before they decay over time. However, monitoring at the time of the binge-eating episode is time consuming and may be resisted by individuals for various reasons (i.e., it interferes with the binge-eating process, it requires the individuals to record painful events that
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Table 6 Percentage of time each item was endorsed on the antecedent checklist Item
Non-binge day
Binge day
p B/A
Informed of something disappointing Received negative feedback Refused an object/activity I requested Evaluated Fight, argument or other negative interaction Disciplined or reprimanded Hurried/rushed more than usual Did not sleep well last night Changes in my living environment Expected visitors (family/friends) Expected visitors who did not arrive Had visitors Felt unusually tired/fatigued Felt agitated/irritable Felt down/sad Felt ill Limited food intake over previous 12}24 hrs Desirable (binge) foods were available Alone for a long period of time during the day Consumed alcohol today Consumed more food than I wanted to
16 12 5 15 13 3 22 29 7 9 3 24 26 15 18 14 7 20 3 14 13
19 18 5 15 22 5 29 40 13 11 6 24 45 29 41 18 23 74 33 22 31
0.54 0.60 0.50 0.50 0.63 0.63 0.57 0.58 0.65 0.55 0.67 0.50 0.63 0.66 0.69 0.56 0.77 0.79 0.92 0.61 0.70
Note: p B/A re#ects the probability of the occurrence of a binge given the occurrence of the antecedent.
they are trying to ignore or supplant, it may draw attention to the individual if others are present). Therefore, retrospective reporting o!ers a valuable complement to real-time monitoring. Retrospective reporting is easier and more convenient to carry out than real-time recording because it does not require data collection at the time of the binge-eating episode. As long as researchers understand the limitations of retrospective reporting, the information may be a valuable adjunct to that gathered at the time of the binge-eating episode. This investigation enhances our understanding of binge eating by pointing to the operant functions that the behavior may serve for individuals. Identi"cation of antecedent conditions that are generally aversive to the individual with subsequent changes in these conditions during binge eating suggests that binge eating is maintained by negative reinforcement. The negative reinforcement function identi"ed in this investigation is consistent with the results of other investigations that suggest that binge eating brings momentary relief from aversive conditions such as depressed mood, anxiety and anger (e.g., Abraham & Beumont, 1982; Kenardy et al., 1996; Schlundt & Johnson, 1990). The strength of this investigation relative to many previous investigations is the demonstration of these functions with real-time recording. It is clear from this study as well as previous studies that binge eating serves functions that di!er across individuals. It is important to note that binge eating is
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likely to be most e!ectively treated utilizing interventions speci"c to the identi"ed function (Lee & Miltenberger, 1997; Waters et al., 1999). Therefore, it is necessary for clinicians to assess the function of binge eating for each individual in order to develop the most e!ective intervention. The methods utilized in this study provide an example of relatively e$cient assessment techniques to identify the function of binge eating for individuals. A limitation of this study is that the sample consisted of a relatively small number of college students. Therefore, these "ndings may have limited generalizability to other individuals who engage in binge eating. In addition, the small sample-size did not permit comparisons between participants with symptoms of bulimia nervosa versus binge eating disorder. Replication of the study with a clinical population of individuals with bulimia nervosa and binge eating disorder is warranted. The second limitation of the study is that we have no evidence that the participants recorded the antecedents and consequences of binge eating at the time binge eating occurred as instructed, even though all participants reported that they did. Future research using hand-held computers or electronic recorders for data collection would enable researchers to pinpoint the exact time that recording took place. The use of such equipment would help insure the integrity of the assessment. However, even with such equipment, we could not be certain that recording took place at the time that binge eating occurred, because there is no independent veri"cation of the time of binge eating. One possible solution to this problem is to have participants record at intervals, throughout the day, when signaled by the electronic data device. A record of mood, cognitions, interpersonal events and other possible antecedents throughout the day would allow researchers to track these events and investigate their relationship to binge eating. Such signaled interval recording would be a useful adjunct to event-related recording at the time of binge eating. Future research should also seek to more clearly delineate the function of binge eating for individual participants so that the most relevant treatment can be delivered. For example, treatment would be di!erent for an individual whose binge eating brings relief from depressed mood than for an individual whose binge eating resulted in relief from anxiety. Although the binge eating for both individuals is negatively reinforced by reduction in an aversive condition, treatments for the two individuals would di!er; one focusing on alleviating depression and the other on anxiety-reduction. One "nal avenue for future research is the demonstration that functional treatments for binge eating are most e!ective. If treatments based on functional assessment results are more e!ective than generic treatments, then the validity of functional assessment is enhanced. Although it makes sense that functional treatments would be most e!ective based on the results of treatment for other behavior disorders (Iwata et al., 1994; Kearney & Silverman, 1990), the relative e$cacy of functional treatments for binge eating has yet to be established. References Abraham, S. F., & Beumont, P. J. V. (1982). How patients describe bulimia or binge eating. Psychological Medicine, 12, 625}635.
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