Distressed binge eaters as a distinct subgroup among obese individuals

Addictive Behaviors, Vol. 16, pp. 441451, Printed in the USA. All rights reserved.

1991 Copyright

0306-4603/91 $3.00 + .oo Q 1991 Pergamon Press plc

DISTRESSED BINGE EATERS AS A DISTINCT SUBGROUP AMONG OBESE INDIVIDUALS MARIAN L. FI’IZGIBBON and DANIEL S. KIRSCHENBAUM Northwestern

University

Medical School

Ah&act - This study was conducted to examine the degree to which binge eating and psychological distress among obese adults are associated with a variety of behavioral patterns and competencies that could substantially affect weight control. Subjects were 167 obese people who sought help in a long-term cognitive behavioral treatment program. Subjects were divided into three groups depending on their level of psychological distress and severity of binge eating. Subjects were also assessed on coping style, subjective distress, weight history, and exercising and eating patterns. Results demonstrated substantial differences between those reporting relatively few problems with binge eating or psychological distress as opposed to those with noteworthy problems in both. The presence of either severe binge eating or psychological distress was associated with problems in regulating food-related behavior and, more generally, to problematic coping styles. These findings support the importance of in-depth assessment when treating obesity, more intensive treatment for some subgroupings, and long-term studies that incorporate comprehensive pretreatment process measure of eating style and psychological distress.

Prevailing commercial and professional treatments for obesity often ignore the importance of the heterogeneity of functioning among obese individuals. Professionals continue conducting relatively brief standardized treatments and devote surprisingly little attention to assessment (see Brownell & Jeffery, 1987). Commercial programs, which are the dominant interventions used by obese people seeking assistance from others (Jeffery & Forster, 1987), usually include no assessment of psychological status. The present study was conducted to add evidence to a small but growing body of literature that clearly suggests that assessment of psychological status may well be vital to treat obesity successfully. The de-emphasis of assessment in most obesity treatment programs may have emerged because some professionals view obese individuals as a relatively homogeneous group of basically stable individuals (Kirschenbaum, 1988). This assumption of homogeneity probably derives from research with nonpatient populations that has revealed few differences in personality and adjustment between obese and nonobese groups (e.g., Hoiberg, Berand, & Watten, 1980). More recent research, however, reflects considerable heterogeneity among those who seek treatment for obesity (e.g., Marcus, Wing, & Hopkins, 1988; Pekarik, Blofgett, Evans, & Wierzbicki, 1984). Careful assessment may reveal subgroupings of obese patients who evidence specific types of disturbances and for whom variations from standard treatment approaches may be warranted (e.g., referrals for concurrent psychotherapy; intensification of treatment). Those findings would encourage far broader and more thorough assessments in obesity treatment programs than those currently conducted. Obese binge eaters who also report considerable psychological distress may be a particularly important subgroup of obese individuals. Approximately 50% of obese individuals who seek treatment report clinically significant degrees of binge eating (e.g., Keefe, Wyshogrod, Weinberger, Argas, 1984; Loro & Orleans, 1981; Marcus, Wing, & Lamparski, This research was supported in part by a grant to the second author from Sandoz Nutrition Corporation. Requests for reprints should be sent to Dr. Marian L. Fitzgibbon, Northwestern University Medical School, Department of Psychiatry and Behavioral Sciences, 446 E. Ontario, Chicago, IL 60611. 441

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MARIAN L. FITZGIBBON

and DANIEL S. KRSCHBNBAUM

1985). Among this large subset of obese individuals are those who also report considerable psychological distress. Loro and Orleans (1981) found that obese binge eaters were more likely than their nonbingeing counterparts to have been in psychotherapy. In addition, two recent relatively small-scale studies reported positive correlation between binge eating and various measures of psychological distress (Fitzgibbon & Kirschenbaum, 1990; Marcus et al., 1988). Obese invdividuals who evidence clinically significant binge eating and psychological distress would not be expected to lose weight or maintain losses effectively according to most analyses of the determinants of success in weight control (e.g., Brownell & Jeffery, 1987; Fitzgibbon & Kirschenbaum, in press; Kirschenbaum, 1987; Petri, 1987). Successful weight control places many abnormal demands on people to maintain remarkably consistent eating, exercising, and self-regulatory patterns despite physiological, emotional, and environmental leanings to the contrary. Those individuals who undertake the arduous journey toward long-term weight control with baggage that includes chaotic eating styles and excessive psychological stressors face an especially long and difficult road. Two treatment studies have supported this expectation by showing that obese binge eaters had greater difficulties than their obese peers, who reported less frequent or pervasive binge eating tendencies, with losing weight during short-term behavioral treatment programs or maintaining weight losses when assessed at 6-month follow-ups (Keefe et al., 1984; Marcus et al., 1988). However, some inconsistencies in outcomes are apparent within these studies. For example, Marcus et al. (1988) found that only some obese binge eaters were more likely to drop out of treatment than others @ < .07) and that differences in weight change were not apparent at a l-year follow-up in their study. The two studies that examined the impact of pretreatment binge eating on weight loss outcomes (Keefe et al., 1984; Marcus et al., 1988) did not differentiate obese binge eaters who also reported psychological distress compared to better adjusted obese binge eaters. Some of the inconsistencies in the outcomes obtained in the studies may have been due to the inclusion of binge eaters who managed aspects of their lives relatively well. These better adjusted obese binge eaters may have been able to withstand the stress of weight control regimens more effectively than obese binge eaters who also reported significant distress prior to treatment. Psychological distress per se has not predicted treatment outcomes clearly (Cooke & Meyers, 1980; Weiss, 1977). However, some limitations in size of samples, diversity of samples, and adequacy and duration of treatments may account for most of the inconsistencies in those findings (Fitzgibbon & Kirschenbaum, in press.) Another plausible explanation for some of the latter inconsistencies is that the combination of psychological distress and binge eating, rather than the presence of either factor alone, may presage nearly insurmountable difficulties for obese individuals who want to lose weight and keep it off. It is clear that we need large-scale and long-term treatment outcome studies that include thorough pretreatment assessments of binge eating and psychological distress in the context of a state-of-the-science intervention program. However, at this juncture it could also be useful to examine more closely the degree to which binge eating and psychological distress are associated with a variety of behavioral patterns and competencies that should affect treatment outcome. A study that included a large sample size and examined the degree to which binge eating and psychological distress combine to affect potentially key factors with weight control would serve many purposes. It would help reinforce the importance of assessment in the treatment of obesity, argue against the assumption of homogeneity of functioning among obese individuals, and provide a more compelling rationale for the conduct of large-scale treatment outcome studies with multi-year follow-

Distressed binge eaters

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ups that seem warranted as the next steps. Accordingly, the present study included assessment of binge eating, psychological distress, and behavioral patterns associated with weight control using a large sample of diverse obese individuals who sought treatment in an intensive cognitive-behavioral weight control program. We expected that reports of binge eating problems and psychological distress would combine in an additive fashion to identify a subgroup of obese individuals who seem quite distinct from those who report less binge eating or less psychological distress. METHOD

Subjects

The sample consisted of 167 individuals: 133 women and 34 men. Their mean age was 41.4 years (SD = 10.8 years, range 16-77 years). Their mean weight was 259 lb. (SD = 89 lb.) and mean percent overwieght was 86% (SD = 75%). The mean percent overweight was calculated using the median for medium frame as the ideal weight based on the 1983 Metropolitan Life Insurance Co. Standard Height-Weight Tables. Forty-one percent of tbe sample were single; 44% were married; 11.5% were separated or divorced; and 2.5% were widowed. They were fairly well educated, with more than 75% having attended’some college. Procedure The subjects were 167 consecutive intakes in the People at Risk (PAR) Weight Control

Program (Kirschenbaum, 1988), which is part of the Eating Disorders Program at Northwestern Memorial Hospital in Chicago. Patients were sometimes referred to the program by their primary physician due to health problems related to their obesity, and others heard about the program from friends, associates, or through the media. Each subject completed a 2-hour screening procedure. During the first hour, subjects completed self-report questionnaires assessing eating patterns, coping style, intensity and frequency of binge eating, psychological distress, frequency of exercise, and weight history. The second hour entailed a detailed interview with a psychologist or an advanced doctoral student, who reviewed the self-report questionnaires prior to the interview. The patient was then assessed on past and present psychological functioning, social and occupational history, history of weight loss attempts, current eating patterns, and commitment to weight loss. The 167 subjects in the study were divided into three groups depending on their scores on the Binge Scale (Hawkins & Clement, 1980) and the Borderline Syndrome Index (BSI) (Conte, Plutchik, Karasu, & Jerrett, 1980). The groups included (a) low binge-low BSI (N = 83); (b) mixed binge-mixed BSI (ZV= 60); (c) high binge-high BSI (N = 24). A mixed binge-BSI group was created due to the small cell size (N = 10) of a low bingehigh BSI group and the heterogeneity of variance associated with this small group. There are no established cutoffs for defining binge eating severity using the Binge Scale. However Wing, Marcus, Epstein, and Kupfer (1983) found that aproximately 46% of a sample of 432 women reported a significant binge eating problem. Loro and Orleans (1981) also found that approximately 50% of 280 obese patients reported bingeing at least once per week. Therefore, we used the median score on the Binge Scale as a cutoff. On the BSI, a score of 17 was used to designate high and low BSI groups. Conte et al. (1980) demonstrated that 95% of a sample of “normal” subjects scored below 17. The use of three groups afforded a means to test the additive effects of binge eating and psychological distress on a variety of important measures.

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Measures Binge scale. Hawkins and Clement (1980) developed this g-item scale self-report questionnaire to assess propensity and attitude toward binge eating. It assesses the frequency of bingeing, the duration of each binge, the presence of purging, the degree of control experienced, and mood following the binge. The internal consistency of the Binge Scale is satisfactory (Cronbach’s alpha = .69), and l-month test-retest reliability of the total scores was .88 (Hawkins & Clement, 1980). Borderline Syndrome Index (BSZ). The BSI (Conte et al., 1980) is a 52-item symptom checklist assessing characteristics used as criteria for the diagnosis of borderline personality disorder in DSM-III-R. Subjects are asked to respond “yes” or “no” to statements such as, “It’s hard for me to make decisions,” “ Sometimes I feel I’m falling apart,” and “People disappoint me.” The reliability of the BSI as shown by the Kuder Richardson Formula 20 was .92 (p < .OOOl), indicating high internal consistency. Sympfom Checklisr-90 (SCL-90). The SCL-90 (Derogatis, Lipman, & Covi, 1973) is a 904tem self-report checklist of psychopathology. The primary symptom dimensions measured by the SCL-90 are somatization, obsessive-compulsive disorders, interpersonal sensitivity, depression, anxiety, hospitality, phobic anxiety, paranoid ideation, and psychoticism. Dimensions l-5 have been empirically tested in a number of studies (e.g., Derogatis, Lipman, Covi, & Rickels, 1972; Rickels, Lipman, Garcia, & Fisher, 1972). Dimensions 6-9 have been integrated with the five original dimensions to provide better representation of outpatient symptomatology. In our study, the Grand Symptom Index (GSI) was used rather than the individual dimensions. The GSI is computed by adding the score for each of the 90 questions and dividing by the total number of questions. The Weight History Questionnaire (WHQ). The WHQ was developed in the PAR program (Fitzgibbon & Kirschenbaum, in press; Kirschenbaum, 1988) containing various items regarding weight gain and dieting patterns, number of previous weight loss attempts, and level of success on each one. Items also include demographic information and availability of social support. Dieter’s Inventory of Eating Temptations (DIET). The DIET (Schlundt & Zimmering, 1988) is a self-report questionnaire designed to assess behavioral competence in relation to weight control comprising six factors. These include overeating, exercise, positive social eating, negative emotional eating, food choices, and the ability to resist temptation. Each of the questions asks people to assess what percentage of time (l-100%) they would respond in a particular way to a situation. For example, a question in the negative emotional eating subscale is, “You are having a hard day at work and are anxious and upset. You feel like getting a candy bar. What percent of the time would you find a more constructive way to calm down and cope with your feeling?” Test-retest correlations have been shown to be adequate for the subscales (.68-.92). The DIET subscales showed generally moderate to high intercorrelations (.29-.75). However, two subscales (exercise and negative emotions) were exceptions to this pattern. In addition, the l- to 2-week testretest coefficients were very high, suggesting that the DIET has adequate short-term stability. Validity of the DIET was evaluated by comparing differences between overweight and normal weight subjects. Scores showed that the overweight subjects differed significantly from the normal weight subjects on three of the six diet scales: overeating, nega-

Distressed binge eaters

tive emotions, and exercise. A second validation step positively actual eating patterns as measured by self-monitoring.

445

correlated DIET scores to

Coping Strategies Znventory (CSZ). The CSI (Tobin, Holroyd, Reynolds, & Wigel, 1989), is a 40-item, Likert format, self-report questionnaire assessing coping in response to a specific life stressor. The questionnaire requests that the individual describe a stressful event and then answer 40 questions in relation to how he or she coped with the event. There are 14 subscales of CSI including eight primary scales, four secondary, and two tertiary scales. The tertiary scales (engagement and disengagement) were used for the present study. According to Tobin et al. (1989), an engaged coping style is one where a person actively engages a stressor, with either problem-focused or emotion-focused coping strategies. A disengaged style of coping uses strategies to avoid thinking about or actively handling the stressor. The reliability coefficients for the CSI range from .71 to .94. The CSI has been found to have adequate criterion validity in that it has successfully discriminated symptomatic and normal samples (Tobin, Holroyd, Reynolds, & Wigel, 1985; Tobin, Holroyd, Reynolds, & Wigel, 1989) and adequate construct validity (Tobin, Holroyd, Garske, Molteni, Flanders, Malloy, & Margolis, 1983). Exercise Expenditure Survey. The EXE (cf. Paffenberger, Wing, & Hyde, 1978) is a questionnaire measuring amounts of kilocalories expended in various forms of exercise over a 2-week period.

RESULTS

There were no significant differences between the three groups on age, sex, educational level, marital status, age they first became overweight, or percent overweight. The distribution of Binge Scale scores and BSI scores are presented in Figures 1 and 2 to show the normal distribution of scores on the Binge Scale and the substantially lower prevalence of character disturbance for this group when compared to a nonobese eatingdisordered sample (cf. Johnson, Tobin, & Enright, 1989). A correlational analysis was conducted to assess the relationship between the variables. Some of the key correlations showed low but significant relationships - for example, the SCL-90 and BSI (r = .42, p < .OOl); the SCL-90 and Bingetot (r = .18, p < .OOl); BSI and Disengaged Coping (r = .43, p < .OOl); Bingetot and Disengaged Coping (r= .34, p < .OOl); BSI and Engaged Coping (r = - .19, p < .OOl); and Bingetot and Engaged Coping (I = - .15, p < .Ol). There were 13 dependent variables which were clustered into three categories, and a multivariate analysis of variance (MANOVA) was conducted on each cluster. The three clusters were (a) behavioral competence in relation to weight control, which included seven dependent variables - the six subscales for the DIET questionnaire (resisting temptation, inclination to exercise, positive social eating, overeating, food choices) and the amount of exercise reported in the past 2 weeks (in kilocalories); (b) psychological distress, which included three dependent variables - SCL-90, and the CSI subscales of engaged and disengaged coping; and (c) past history, which included three dependent variables - number of previous diets, heaviest weight, and the availability of spouse or roommate for support for weight loss. The overall MANOVA for behavioral competence in relation to weight control and exercise was significant, Wilkes lambda + .80, Rao F(14, 296) = 2.47, p < .Ol. Follow-up univariate tests of the multivariate group effect showed significant effects for the subscales of overeating, negative emotional eating, resisting temptation, and positive so-

MARIAN L. FITZGIBBON and DANIEL S. KIRSCHENBAUM

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35 N U m b e r 0

30 25 20

f P a t i e n t

15 10 5

S

0

0

2

4

6

8

m

10

12

14

16

18

20

Binge Score

Fig. 1. The distribution of scores for the Binge Scale.

I

N U

m b e r

40

c

30

20

10

0

0

4

8

I2

16

20 m

24

28

32

BSI Scores

Fig. 2. The distribution of scores for the BSI.

36

40

44

48

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Distressed binge eaters

Table 1. Croup differences

Scale Negative emotional eating Resisting temptation Positive social eating Overeating

on the DIRT questionnaire

Low Binge/ Low BSI (N = 83)

Mixed Binge/ Mixed BSI (N = 60)

High Binge/ High BSI (N = 24)

M= 44.7,

M=38.1,

M=34.4,

SD= 11.5 M=48.8, SD=9.3

SD=9.8 M=43.1, SD= 10.5

SD=5.6 M=41.1, SD=8.5

M=52.2,

M=47.6,

M=44.1,

SD= 12.3 M=48.7, SD= 10.6

SD = 12.4 M=43.9, SD=8.1

SD= 16.4 M=41.5, SD=9.0

(2,754)

11.83**** 8.70***

4.06* 6.87**

Note. Higher scores reflect greater competence. Cell means in any row with different subscripts are significantly different from each other (Tukey HSD Multiple Range Tests). *p < .05 **p < .Ol ***p < .OOl

cial eating. These were then followed by Tukey Honestly Significant Difference (HSD) multiple comparison tests. Results showed that Group 1 (low binge-low BSI) reported less overeating than Groups 2 (mixed binge-mixed BSI) and 3 (high binge-high BSI), Rao F(2, 154) = 6.88, p < .Ol. Similarly, the low binge-low BSI group (Group 1) reported less eating following feelings of negative emotion, Rao F(2, 154) = 11.83, p < .OOOl. In addition, Group 1 showed a better ability to resist temptation, Rao F(2, 154) = 8.70, p < .OOl, than the group that scored high on both the BSI and Binge Scale (Group 3) and the group that scored high on one of the two scales (Group 2). Furthermore, Group 1 showed less eating in positive social situations that Group 3, Rao F(2, 154) = 4.05, p < .05. The overall MANOVA for psychopathology was also significant, Wilkes lambda = .59, Rao F(6, 286) = 14.5, p < .OOl. Follow-up univariate tests of the overall group effect showed significant effects for the SCL-90 and CSI disengaged coping subscale (see Table 2). These were followed by Tukey (HSD) multiple comparison tests. Results showed that on the SCL-90, Group 3 (high binge-high BSI) showed the greatest psychological distress; Group 2 showed significantly less distress; and Group 1 showed even less distress, Rao F(2, 164) = 46.6, p < .OOOl. On disengaged coping, Groups 1, 2, and 3 were again all significantly different from each other, Rao F(2, 145) = 14.2, p C .OOOl. Group 3 showed the most disengaged coping style, indicating a reluctance to handle stressful situations actively, and Group 1 reported using this form of coping the least. Figure 3 summarizes and highlights the significant differences between the groups. DISCUSSION The results substantiate the existence of distinct subgroups among obese individuals who seek treatment. The present study demonstrated substantial differences among those who reported relatively little or no binge eating problems and relatively less psychological distress as opposed to those who reported problems in either category and those with problems in both areas. It seems that the presence of either relatively severe binge eating or psychological distress is associated with the way these individuals regulate their behaviors in relation to food. The low binge=low BSI subjects were more competent in their reported ability to avoid overeating, eat in response to negative affect, eat in positive social situations, and resist temptations.

448

MARIAN L. FITZGIBBON

and DANIEL S. KIRSCHENBAUM

Table 2. Croup differences

on the CSI and SCL-90 Group

Measure

Low Binge/ Low BSI (N = 83)

Mixed Binge/ Mixed BSI (N = 60)

High Binge/ High BSI (N = 24)

SCL-90

M= .49, SD= .41

M= .76, SD= .41

M= 1.5, SD= 53

CSI disengaged coping

SD=2.3

M= 10.3,

M= 9.0,

46.5* F (2,145)

M=11.8,

SD=2.6

SD=2.9

14.2*

Note. Higher scores reflect greater psychological distress and less adaptive coping. Cell means in any row with different subscripts are significantly different from each other (Tukey HSD Multiple Range Tests). *p < .OOOl

There was a relatively even distribution of binge eating in our sample: 23% reported binge eating once per week and 37% reported binge eating almost every day. These percentages are somewhat similar to those of Loro and Orleans (1981), who reported 28% and 22%, respectively. These are fairly striking percentages given that the presence of binge eating is not usually addressed specifically as a treatment issue in most weight control programs. Given the deprivation that many individuals involved in weight loss programs experience and the literature associating deprivation with binge eating (e.g., Fairborn, 1981; Johnson & Connors, 1987), it seems that some of the standard techniques used to encourage weight loss may be contraindicated with this subgroup - that is, until the binge eating is substantially reduced. There was a more uneven distribution along the dimension of psychological distress, with 20% scoring in a range suggestive of more severe pathology. These results, however, are very similar to our previous study (Fitzgibbon & Kirschenbaum, 1990), in which approximately 23% of a different sample of 60 patients scored in the same disturbed

1

1.5 M e a n

l-

0.5 Z S C 0

r e

S

0

-0.5

-I’

I

Poeltlve S00lal Eating

dpif% 0

I

overeating lpc.01)

I

I

Negative Affeot

Reeletlng Temptation

~pc.001)

Binge Low BSI ‘nmss’

,5%“09, m

I

,

SCL-90 fpUXl01)

DIeengaged Coping

(p~.ooor)

Mixed Binge/BSI

‘nmro’

High Binge High BSI’H*P4’

Fig. 3. Differences

between groups with high, intermediate,

and low Binge Scale and BSI scores.

Distressed binge eaters

449

range. Again, there is a distinct subgroup that may not respond as readily to standard cognitive-behavioral interventions and may need more intensive and varied forms of treatment. There were significant differences between each of the three groups on subjective distress and coping. These results suggest that when more severe binge eating and higher levels of psychopathology appear together, there are implications for overall subjective distress, coping ability, and perhaps for treatment. Given that significant differences in affect and cognition have been found between binge and nonbinge eaters prior to a behavioral weight program (Marcus et al., 1988) and that weight loss seemed to have no impact on the binge eaters’ subjective distress, it may be that individuals with severe binge eating and higher levels of distress need alternative forms of treatment. Certainly the implications for the treatment of serious binge eating and more severe psychological distress need to be addressed in depth during an assessment interview. The relatively higher drop-out rate of obese binge eaters found in a short-term study (Marcus, et al., 1988) may have been because time-limited, structured group, cognitive-behavioral weight loss programs are not intensive, individualized, or flexible enough for this subgroup. Clearly, more empirical studies looking at long-term outcome differences between groups with varying levels of bingeing severity and overall functioning are needed. The correlational analysis showed that there are low but significant relationships between some of the independent and dependent variables. It is important for future researchers to understand that there may be some overlap in what these variables are measuring (e.g., between the BSI and the SCL-90). The primary implications of our results pertain to assessment and the existence of subgroups within an obese population. However, there are two other aspects of our data that warrant attention. The first pertains to diet history and its importance in relation to differentiating groups of obese individuals. Fitzgibbon and Kirschenbaum (1990) found no significant differences between high and low BSI groups on diet history, and the present study also showed no differences between the three groups on heaviest weight, number of previous diets, or support from a spouse or roommate. Gormally, Rardin, and Black (1980) found that a history of more dieting coupled with more severe binge eating was associated with poor weight loss maintenance. It seems, however, that despite binge eating severity or level of psychopathology, there have been no indications in two of our samples that one group had ever been heavier, had more support, or been on more diets. Gormally et al. ‘s findings may have been due more to the presence of problematic eating and perhaps psychological distress than to a history of dieting. In the PAR program, we have observed that almost all potential participants report elaborate histories of dieting. This possible ceiling effect may obscure any significance of this variable as a consistent predictor of weight control outcomes. The second issue pertains to coping style and its relevance to weight control. Our results suggest that within the broader obese population there are subgroups that differ on potentially important variables in relation to weight control. For example, our data suggest that those experiencing both more pronounced psychological distress and binge eating had a less adaptive coping style. It seems clear that assessment of coping style prior to treatment merits attention because effectiveness of coping strategies is demonstrating increasing importance in overcoming addictive problems (e.g., Bliss, Garvey, Heinhold, & Hitchcock, 1989; Marlatt & Gordon, 1985). The avoidant coping style of the high binge-high BSI subgroup in this study and their propensity not to share thoughts and feelings with others may be especially problematic. This style may lead them to drop out of treatment rather than address the fact that the program was not meeting their needs. Staying in treatment for obesity has clearly emerged as perhaps the single most important

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contributor to long-term success (e.g., Petri, Nezu, Patti, & McCann, 1989). Hence, the standard approach in treating obese individuals may not be intense enough to help distressed binge eaters change their maladaptive coping style or, relatedly, to stay in treatment long enough to succeed (cf. Kirschenbaum, 1987). They may be in need of more in-depth treatment in this specific area and more individualized attention before weight loss can be pursued effectively. The present results and related findings (Fitzgibbon & Kirschenbaum, 1990; Marcus et al., 1988; Pekarik et al., 1984) clearly support the value of in-depth assessment procedures in research and clinical practice with obese individuals. As this kind of research progresses, it will become clearer who can benefit most from standard cognitive-behavioral weight loss programs and who may need other interventions or more intensive treatment to achieve the extremely challenging and elusive goal of permanent weight control (cf. Brownell & Jeffery, 1987; Kirschenbaum, 1988).

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