binge eating disorder

download binge eating disorder

of 23

description

eating disorders

Transcript of binge eating disorder

  • 5/27/2018 binge eating disorder

    1/23

    ASSESSMENT AND TREATMENT OFBINGE EATING DISORDERWILLIAM G . J O H N S O N and LAINE J . TORGRUII

    Perhaps the most salient topic in the eating disorders literature overthe past few years has been binge eating, and several factors have contrib-uted to this burgeoning interest. First, binge eating is ubiquitous, beingwidely distributed in both eating-disturbed and normal populations. It haslong been recognized as a serious clinical problem in obesity Loro & Or-leans, 1981; Stunkard, 1959) and anorexia nervosa Garfinkel, Moldofsky,& Garner, 1980), and binge eating is central to the diagnosis of bulimianervosa and the newly proposed binge eating disorder American Psychi-atric Association, 1994). Furthermore, binge eating is observed with trou-blesome frequency in college populations Halmi, Falk, & Schwartz, 1981;Hawkins & Clement, 1980).A second factor promoting interest in binge eating concerns its re-lationship to several important clinical features. Bingeing increases withadiposity Telch, Agras, & Rossiter, 1988), and it is associated with psy-chopathology in individuals with obesity Kolotkin, Revis, Kirkley, & Jan-ick, 1987; Marcus et al., 1990a), anorexia nervosa DaCosta & Halmi,1992), and nonpurging bulimic individuals Prather & Williamson, 1988).Binge eating is also related to poor treatment outcome for obesity Keefe,Wyshogrod, Weinberger, & Agras, 1984; Marcus, Wing, & Hopkins, 1988).A third factor encouraging attention to binge eating is the develop-ment of diagnostic categories in which binge eating is the most prominent

    321

  • 5/27/2018 binge eating disorder

    2/23

    characteristic. Binging was a major component of bulimia nervosa in DSM-III (American Psychiatric Association, 1980), yet research following thepublication of DSM-III criteria for bulimia nervosa soon identified twogroups of bulimic patients: those who purged and those who did not. InDSM-III-R (American Psychiatric Association, 1987), bingeing and purg-ing became criteria for bulimia nervosa, and a diagnostic impasse emergedfor obese binge eaters (e.g., Marcus et al., 1988; Marcus, Smith, Santelli,& Kaye, 1992) and nonpurging bulimic patients (e.g., McCann, Rossiter,King, & Agras, 1991). Spitzer et al. (1991) proposed that such individualsbe diagnosed w i th binge eating disorder (BED), with binge eating as itscentral feature.

    While some have argued that the proposed BED category is premature(Fairburn, Welch, & Hay, 1993), two multisite studies support the exis-tence of a distinct BED syndrome, w i th approximately 30% of the obesepopulation and 2 to 5% of the general population satisfying diagnosticcriteria (Spitzer et al., 1992, 1993). In addition, BED has been associatedwith severe obesity, marked weight fluctuations, impaired social and workfunctioning, overconcern with body shape and weight, psychopathology,amount of adult lifetime spent on diets, and a history of treatment foremotional problems. Presently, BED has been included in the appendix ofDSM-IV as a category warranting further study (American Psychiatric As-sociation, 1994).

    CHARACTERISTICS OF BINGE EATING DISORDERThe proposed diagnostic criteria for BED are listed in Exhibit 1. In

    brief, the diagnosis requires that binge episodes occur at least twice weeklyfor 6 months and be experienced as distressing. Also, for an eating episodeto be identified as a binge, it must satisfy at least three of the five associatedfeatures in section B of Exhibit 1. Because the diagnosis of BED is a recentdevelopment, only a handful of studies have targeted subjects satisfying theformal criteria for the disorder (e.g., Fichter, Quadflieg, & Brandl, 1993;Nangle, Johnson, Carr-Nangle, & Engler, 1994; Yanovski et al., 1992).Fortunately, information prior to the development of formal BED criteriacan be gleaned from the literature on obese binge eaters and nonpurgingbulimic patients-many of whom would satisfy current criteria for BED(Antony, Johnson, Carr-Nangle, & Abel, 1994). Together these groups willbe referred to as pre-BED subjects.Binge Eating Behavior

    Central to the diagnosis of BED is binge eating, and research hasaddressed its frequency, size, composition, duration, and relation to ante-cedents and consequences in both pre-BED and BED populations.322 J O H N S O N A N D T O R G R UD

  • 5/27/2018 binge eating disorder

    3/23

    EXHIBIT 1Proposed DSM IV Diagnostic Criteria for Binge Eating DisorderA Recurrent episodes of binge eating, an episode being characterized by both ofthe following:1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amountof food that is definitely larger than most people would eat during a similarperiod of time in similar circumstances.2. A sense of lack of control during the episodes, for example, a feeling that onecannot stop eating or control what or how much one is eating.

    1. Eating much more rapidly than usual.2. Eating until feeling uncomfortably full.3. Eating large amounts of food when not feeling physically hungry.4. Eating alone because of being embarrassed by how much one is eating.5. Feeling disgusted with oneself, depressed, or feeling very guilty after over-

    C Marked distress regarding binge eating.D The binge eating occurs, on average, at least twice a week for a 6-month period.E. Does not occur only during the course of bulimia nervosa or anorexia nervosa.

    6 During some of the episodes, at least three of the following:

    eating.

    __From Spitzer t al. (1993)

    FrequencyBinge frequencies in excess of those required by DSM-IV diagnostic

    criteria have been reported in studies of both pre-BED and BED individ-uals. For example, Marcus et al. (1992), employing a semistructured inter-view, obtained an average reported binge frequency of approximately 16.0episodes in 28 days for obese binge eaters. Average frequencies over 10weeks have been found for nonpurging bulimic subjects (Rossiter, Agras,Telch, & Bruce, 1992). In a comparison of BED, nonclinical binge eaters,and normal subjects, Johnson, Schlundt, Barclay, Carr-Nangle, and Engler(1995) found that BED subjects were more likely to identify eating episodesas hinges (36.2 of episodes vs. 23.2 for nonclinical binge eaters and12.1 for normal subjects). These data translate to a weekly binge fre-quency of approximately 10 for BED subjects, 7 for nonclinical binge eaters,and 3 for normal subjects. Clearly, binge eating is a frequent phenomenonin clinical populations and in many normal individuals who may not satisfyother diagnostic criteria. I t has been suggested that number of binge days,as opposed to the frequency of binge episodes, may be the preferred indexof binge severity in nonpurging subjects because of the difficulty of de-marcating binge episodes that do not end with purging (Rossiter et al.,1992). This difficulty in specifying the termination of a binge contributesto the problem of defining binge episodes, an issue that pervades researchon the various aspects of binge behavior.

    ASSESSMENT AND TREATMENT OF BINGE EATING DISORDER 323

  • 5/27/2018 binge eating disorder

    4/23

    Amount and CompositionStudies investigating the amount of food consumed during binge ep-

    isodes reveal considerable variability. Using self-monitoring records, Ros-siter et al. (1992) reported an average consumption of approximately 600kcal (range: 25-6000) in nonpurging bulimic patients. This finding con-trasts w i th the laboratory study of Yanovski et al. (1992) on a BED samplein which an average of nearly 3000 kcal (range: 2300-3600) was observed.This difference in self-monitored versus laboratory estimates of caloric con-sumption is no doubt a result of methodological variables such as demandcharacteristics among others and is also evident in similar studies on sub-jects with bulimia nervosa (e.g., Rossiter & Agras, 1990; Walsh, Kissileff,Cassidy, & Dantzic, 1989). Regardless of actual size, however, it is clearthat binge episodes vary greatly among individuals w i t h BED. Variabilityin the size of binges and the number that are relatively small in size hasled to the recommendation that size be deemphasized as an operationalcriterion for binge (Rossiter & Agras, 1990).

    Data on food composition confirms that binges typically involve highcalorie, fattening foods (Loro & Orleans, 1981; Marcus et al., 1988) withthe likelihood of macronutrient differences between binge and normalmeals. Rossiter et al. (1992) found that the binge episodes of pre-BEDsubjects typically involved consumption of less protein and fiber than wasconsumed on nonbinge days, with a difference in fat content approachingsignificance. The results of laboratory studies are consistent with the self-report data in showing that obese women meeting BED criteria consumeda greater percentage of energy as fat than did non-BED obese subjects(38.9 vs. 33.5 ) and a lesser percentage as protein (11.4 vs. 15.4 )when both groups were instructed to binge (Yanovski et al., 1992).Duration

    Similar to the data on amount, data on the duration of binges alsodisplays considerable variation. To illustrate, Rossiter et a1.k 1992) non-purging bulimic subjects reported binge lengths ranging from 1 to nearly900 minutes (averaging around 40). Binges in the upper end of this rangeappear to violate the DSM-IV specification of occuring in a discrete periodof time (American Psychiatric Association, 1994, p 545). Excluding bingeepisodes of lengthy duration may constitute a significant problem becausenearly 24 of binge episodes identified by Marcus et al.s (1992) subjectslasted the entire day. Measuring binge days has been offered as an alter-native (Rossiter et al., 1992).Loss of Control

    The variability in amount and duration of binge episodes may beaccounted for by subjective variables such as loss of control. Consistent324 JOHNSON ND TORGRUD

  • 5/27/2018 binge eating disorder

    5/23

    with this notion, Johnson, Carr, Zayfert, Nangle, r Antony (1993) pro-vided both non-eating-disordered peers and dieticians with 3 weeks of self-monitoring records of BED and nonclinical bingeing subjects. There waslittle agreement between the judgments of the subjects themselves regard-ing the status of their own eating episodes (binge vs. nonbinge) and thejudgments of peers and dieticians based solely on amount and durationcriteria. This disagreement suggests that subjective information availableonly to the subjects, such as the degree of perceived control during aneating episode, may significantly influence perceptions of the nature ofeating episodes. This finding also raises the possibility of defining bingeepisodes exclusively from the patients perspective (Johnson et al., 1993).Although clinician-patient collaborative judgments likely will continue tobe the standard (Cooper & Fairburn, 1987), the literature provides com-pelling support for emphasizing this subjective dimension (Beglin & Fair-burn, 1992).

    Antecedents and ConsequencesNegative emotional states, social situations, time of day, and the type

    of meal have been associated with bingeing in BED. Arnow, Kenardy, andAgras 1992) interviewed pre-BED individuals about their thoughts andfeelings that occurred before, during, and after a binge episode. Negativemoods were common preceeding binges, with the most predominant beinganger and frustration, anxiety and agitation, and sadness and depression.Emotions occurring during binge episodes were evenly split between neg-ative and positive, and those following a binge were overwhelmingly neg-ative, wi t h guilt, regret, and self-directed anger evident.

    Johnson et al. (1995) examined emotions and other situational var-iables associated with eating behavior for BED, nonclinical binge eaters,and normal subjects. BED subjects were equally likely to binge whetheralone or with others and whether at home or in a restaurant. BED subjectswere also unique by virtue of a strong association between bingeing andsnacking, particularly after midnight. Also, in contrast to the comparisongroups, the BED subjects showed no relationship between feeling very hun-gry and bingeing. Rather, these individuals typically felt full when theywere bingeing. BED subjects reported greater overall emotional distress as-sociated with eating and a tendency to binge in response to less negativemoods than did nonclinical binge eaters and normal subjects.

    The eating behavior of individuals with BED and pre-BED is char-acterized by frequent binge episodes during which they consume snack anddessert foods. Furthermore, binge eating in BED subjects is more likely tooccur in the evening while snacking and is relatively unaffected by socialvariables. Negative emotional states typically precede and follow binges.

    ASSESSMENT AND TREATMEN T OF BINGE EATING DISORDER 25

  • 5/27/2018 binge eating disorder

    6/23

    Distinctiveness From Bulimia NervosaIn addition to the lack of compensatory behavior, the research evi-

    dence suggests that individuals w i th BED also differ in other clinicallymeaningful ways from those diagnosed w i th bulimia nervosa. Pre-BED sub-jects consume approximately half the calories of those wi th bulimia nervosaduring binges (Rossiter et al., 1992; Rossiter & Agras, 1990; Walsh et al.,1989; Yanovski et al., 1992) and they also binge less frequently (Fairburnet al., 1991; Marcus et al., 1992; McCann et al., 1991). Since the bingeepisodes of bulimia nervosa are easily discriminated by purges (Rossiter etal., 1992), the differences in amount and frequency may be attenuated.

    Further distinctions between BED and bulimia nervosa are evident inthe multisite study in which Spitzer et al. 1993) found that BED subjectsreported a history of severe obesity (defined as a body mass index of 35 orgreater) and greater weight fluctuations than did bulimia nervosa subjects.Higher levels of impairment in work performance, weight and shape con-cerns, depression, alcohol and drug abuse, and sexual abuse, however, wereendorsed more often by subjects with bulimia nervosa. Interesting genderdifferences emerged between BED and bulimia nervosa in that BED isslightly more common in females than males in weight-control patientsand occurs equally in college and community nonpatient samples. In con-trast, females make up the majority of patients w i th bulimia nervosa(American Psychiatric Association, 1987).

    There is also evidence that individuals with BED may differ fromthose with bulimia nervosa in dietary restraint (Brody, Walsh, & Devlin,1994). Marcus et al. (1992) found that bulimic patients scored significantlyhigher than obese binge eaters on the restraint subscale of the Eating Dis-orders Examination, whereas scores for the two groups were similar on theother subscales. McCann et al. (1991) obtained similar data by comparingthe responses of purging and nonpurging bulimic patients. Purging bulimicindividuals scored higher on the restraint measure, as well as disinhibition,relative to nonpurging subjects.

    PsychopathologyThe distinctiveness of the BED syndrome is also evident in compar-

    isons of BED and pre-BED patients with bulimic, obese nonbinge eaters,and normal subjects on measures of psychopathology. Individuals satisfyingvarious pre-BED criteria have lower levels of depression (Brody et al., 1994;Katzman & Wolchik, 1984; McCann et al., 1991; Schmidt & Telch, 1990),lower rates of panic and personality disorders (McCann et al., 1991;Schmidt & Telch, 1990), higher self-esteem (Katzman & Wolchik, 1984),and less tendency toward impulsive and self-defeating behavior (Schmidt& Telch, 1990) than those w i t h bulimia nervosa. By contrast, pre-BED326 JOHNSON ND TORGRUD

  • 5/27/2018 binge eating disorder

    7/23

    individuals score higher on many measures of psychopathology relative toobese subjects (Fitzgibbon & Kirschenbaum, 1990; Kirkley, Kolotkin, Her-nandez, & Gallagher, 1992; Marcus et al., 1988, 1990a) and normal con-trols (Prather & Williamson, 1988; Schmidt Telch, 1990; Williamson,Prather, McKenzie, & Blouin, 1990). To summarize, while the data are notentirely definitive (e.g., see Crowther & Chernyk, 1986; Prather & Wil-liamson, 1988), the general finding is that bulimic patients exhibit thehighest level of psychopathology, followed by pre-BED patients, obese sub-jects, and normal controls, in descending order.

    Studies employing explicit BED diagnostic criteria confirm thesegroup differences (e.g., Fichter et al., 1993; Telch & Agras, 1994). In aprospective study, Antony et al. (1994) used the Questionnaire of Eatingand Weight Patterns (QEWP) to compare BED, nonclinical binge eaters,and normal groups. The BED group reported higher levels of psychopa-thology than normal subjects on measures of depression, anxiety, fatigue,and confusion. In general, conclinical binge eating subjects scored betweenthe BED and normal groups, falling closer to the subjects without eatingproblems. Overall, the available evidence appears to justify the conclusionthat individuals with BED and pre-BED fall somewhere between bulimicpatients and normal subjects on general and specific measures of psycho-pathology (Antony et al., 1994; Schmidt & Telch, 1990). This distinctpattern of psychopathology lends support to the integrity of the BED di-agnosis and, in addition, suggests clinical levels of psychopathology thatdeserve therapeutic intervention.ody Image

    Body image disturbance wi th both size overestimation and dissatis-faction is a significant clinical feature among individuals with anorexianervosa and bulimia nervosa (see Part I this volume). With BED patients,however, body size overestimation appears to be less of a clinical problem,perhaps because their conspicuous obesity precludes significant perceptualdistortion. In contrast, body image dissatisfaction has been a more fruitfulline of investigation with the general finding that individuals meeting BEDcriteria are dissatisfied with their appearance, perhaps because of their ob-jective obesity. Using the Body Image Assessment (see chapter 3, this vol-ume) that requires individuals to select their current and ideal body sizesfrom a set of nine size-graded silhouettes, Williamson, Gleaves, and Savin(1992) found a mean current body size estimate of 8.83 (9 being thelargest), and a mean ideal body size preference of 5.00 for subjects w i t hBED. The difference between current and ideal body size (3.83) is consid-ered a measure of body size dissatisfaction, and large differences consistentlyhave been found in studies comparing BED (Antony et al., 1994) and pre-BED populations (Williamson et al., 1990) to normal controls. Indeed,

    ASSESSMENT AND TREATMENT OF BINGE EATING DlSORDER 327

  • 5/27/2018 binge eating disorder

    8/23

    greater body size dissatisfaction among those with BED occurs even whenthe degree of obesity is covaried (Antony et al., 1994). These data concurwith alternative measures such as the body dissatisfaction subscale of theEating Disorder Inventory (de Zwaan et al., 1994) and the shape concernsubscale of the Eating Disorders Examination (Smith, Marcus, & Kaye,1992) in which pre-BED groups score higher than normal subjects (Cooper,Cooper, & Fairburn, 1989; Garner, Olmstead, & Polivy, 1983).

    The degree of body dissatisfaction exhibited by individuals with BEDversus bulimia nervosa and obese groups is less clear. For example, whileseveral studies suggest greater dissatisfaction among pre-BED and BED sam-ples relative to bulimia (Fichter et al., 1993; Williamson et al., 1990),others show little difference (Williamson et al., 1992). Conflicting dataalso emerge from the literature comparing the body dissatisfaction of BEDand pre-BED subjects to obese subjects. O n the one hand, research supportsa positive relationship between binge severity and body dissatisfaction inobese subjects (de Zwaan, Nutzinger, & Schoenbeck, 1992; Marcus et al.,1990b; but see Lowe & Caputo, 1991) and an association between BEDdiagnosis and weight and shape concern (Spitzer et al., 1993). O n the otherhand, comparisons of pre-BED and obese subjects have found similar bodysize dissatisfaction (Williamson et al., 1990), and comparisons of BED andobese subjects have failed to find differences in Eating Disorder Inventorybody dissatisfaction scores (de Zwaan et al., 1994; Fichter et al., 1993). Atpresent, it seems that individuals with BED are dissatisfied w i th their bodiesand that there is some empirical justification (e.g., de Zwaan et al., 1992;Spitzer et al., 1993) to expect this dissatisfaction to be greater than thatexhibited by non-binge-eating obese persons. These data suggest that anycomprehensive treatment program for BED must include techniques de-signed to modify self-evaluative assumptions and body disparagement, as isthe case in the treatment of obesity (Garner & Wooley, 1991).

    ASSESSING BINGE EATING DISORDERAssessing BED has employed a wide range of methods including ques-tionnaires, self-monitoring, diagnostic interviews, and laboratory observa-

    tion. Because the diagnosis of BED shares with bulimia nervosa a focus onbinge eating, instruments measuring eating behavior have clinical utili tyfor assessing both disorders.Questionnaire Measures

    The Questionnaire of Eating and Weight Patterns (Spitzer et al.,1992, 1993) is the sole diagnostic procedure used exclusively for identifyingBED. Thirteen items serve to classify respondents with BED, purging bu-28 lOHNSON ND TORGRUD

  • 5/27/2018 binge eating disorder

    9/23

    limia nervosa, or nonpurging bulimia nervosa (Spitzer et al., 1993), andpsychometric data on the questionnaire are encouraging. The BED diag-nosis based on the Questionnaire of Eating and Weight Patterns is mod-erately stable over a 3-week interval (kappa = . ; Nangle, Johnson, Carr-Nangle, & Engler, 1994), correlates well with the diagnosis based onstructured interview (kappa = .57; de Zwann, et al., 1993), and differen-tiates high- versus low-frequency binge eaters with sufficient predictive ef-ficiency (71 to 73 ; Nangle et al., 1994).

    The Binge Eating Scale is a 16-item questionnaire originally designedto describe binge behavior and associated thoughts and feelings in theobese (Gormally, Black, Daston, & Rardin, 1982). This scale addressesseveral diagnostic characteristics of BED, including all five aspects of Cri-terion B (see Exhibit 1).The Binge Eating Scale has been shown to iden-tify individuals w i t h no, moderate, or severe binge eating as assessed bystructured interview (Gormally et al., 1982). The Binge Scale is a 9-itemmeasure of binge severity (Hawkins & Clement, 1980). This scale providesinformation on several aspects of Criterion B (Exhibit 1 ) and, unlike theBinge Eating Scale, probes for binge frequency. The Bulimia Test is a 32-item, self-report scale originally designed to measure the symptoms of DSM-III bulimia and to distinguish bulimic from anorexic patients (Smith &Thelen, 1984). The test was revised to accommodate DSM-III-R criteriafor bulimia nervosa (Thelen, Farmer, Wonderlich, & Smith, 1991). Al-though Bulimia Test scores can distinguish obese binge eaters from obesesubjects (Prather & Williamson, 1988) and BED subjects from both sub-clinical binge eaters and normal subjects (Antony et al., 1994), its capacityto distinguish obese binge eaters from individuals with bulimia nervosa isquestionable (Williamson et al., 1990). The Bulimia Test-Revised optionsfor binge frequency are equal to the diagnostic demands of BED, althoughthe 6-month history of binge eating necessary for a diagnosis of BED can-not be determined. The Eating Disorder Inventory is a 64-item scale (Gar-ner et al., 1983),recently revised to 91-items (Garner, 1991), that measuresclinical features of bulimia nervosa and anorexia nervosa (see chapter 9,this volume). The validity of this instrument for BED and related popu-lations has yet to be established, and the few questions pertaining to binge-ing are confined to the bulimia subscale. The potential utility of this in-strument in the assessment of BED, however, can be adduced from itsincreasing use in identifying the characteristics of obese binge eaters (e.g.,de Zwaan et al., 1994).

    The Drive for Thinness and Ineffectiveness subscales, for example,have been shown to predict binge eating severity among the obese (Lowe& Caputo, 1991) and may discriminate subjects satisfying full BED criteriafrom obese binge eaters not meeting criteria (de Zwaan et al., 1994). In-teroceptive awareness may also relate to binge eating status (Kuehnel &Wadden, 1994; Lowe & Caputo, 1991; Marcus et al., 1990b), as may body

    ASSESSMENT AND TREATM ENT OF BINGE EATING DISORDER 329

  • 5/27/2018 binge eating disorder

    10/23

    dissatisfaction (Marcus et al., 1990b), although the latter relationship re-mains equivocal (de Zwaan et al., 1994; Lowe & Caputo, 1991). Bodydissatisfaction and ineffectiveness scores may differ between BED and bu-limia nervosa patients (wi th bulimic patients scoring lower on body dis-satisfaction and higher on ineffectiveness), although these relationshipsdisappear when the body mass index is controlled (Fichter et al., 1993).Among the subscales introduced in the Eating Disorder Inventory-2, im-pulse regulation may be associated w i th BED diagnosis in the obese (Kueh-nel & Wadden, 1994).

    Questionnaires have been developed to assess dietary restraint, a con-cept that occupies a prominent position in current theoretical (Heatherton,Polivy, King, & McGree, 1988; Lowe, 1993; Ruderman, 1986) and empir-ical (Heatherton, Polivy, & Herman, 1989;Johnson, Corrigan, Crusco,Schlundt, 1986; Lowe, 1992) work on eating behavior and its disorders.The initial measure of dietary restraint, the Restraint Scale (Herman &Mack, 1975), has found favor among researchers because it predicts manyof the behavioral phenomena that gave impetus to the concept of restraint(see Lowe, 1993). Other recently developed measures, such as the Three-Factor Eating Questionnaire (Stunkard & Messick, 1985) and the DutchEating Behavior Questionnaire (Van Strien, Frijters, Bergers, & Defares,1986) are popular among researchers because, in addition to cognitive re-straint, they measure functionally related variables such as disinhibitionand hunger.Several lines of evidence suggest that dietary restraint, disinhibition,and hunger are important in assessing individuals w i t h BED. First, individ-uals diagnosed with DSM-111 bulimia nervosa have elevated restraint scalescores (Ruderman, 1985). Second, some evidence suggests a relationshipbetween dieting and binge eating in the obese. Telch and Agras 1993),for example, showed that administration of a very low calorie diet produceda subsequent increase in binge behavior in subjects identified as nonbingingobese. Finally, a number of studies have shown a positive association be-tween indices of restraint and measures of binge behavior or BED diag-nostic status (Antony et al., 1994; Goldfein, Walsh, Lachaussee, Kissileff,& Devlin, 1993; Gormally et al., 1982).

    I t must be acknowledged, however, that the degree of associationbetween restraint and binge eating in individuals with BED remains de-batable (Yanovski, 1993). In contrast to Telch and Agras (1993), weight-loss dieting actually has been shown to reduce the frequency and severityof binge eating among those diagnosed with BED (Yanovski & Sebring,1994). Furthermore, of the individuals with BED surveyed by Spitzer et al.(1993) , 48.6 reported that they began binge eating before dieting, com-pared wi t h 37.0 who reported the reverse.330 l O H N S O N AND TORGRUD

  • 5/27/2018 binge eating disorder

    11/23

    The utility of measures of dietary restraint in the understanding ofBED will depend ultimately on their capacity to predict clinical featuresof the disorder that influence therapeutic interventions. At present, thedisinhibition subscale of the Three-Factor Eating Questionnaire appears tohave particular relevance. I t measures emotional eating (Ganley, 1988),which is consistently elevated in individuals with BED and pre-BED(Fichter et al., 1993; Goldfein e t al., 1993; Marcus et al., 1988). Further-more, scores on this subscale appear to decrease in the course of bothpsychotherapeutic (Wilfley et al., 1993) and pharmacological (McCann &Agras, 1990) interventions that reduce binge eating. I t is interesting tonote that binge reduction in the obese has also been associated with ele-vations on the cognitive restraint subscale that brings their total scoresmore closely in line with the higher scores of bulimic patients (Brody etal., 1994; McCann et al., 1991).

    Each of the questionnaires listed previously has potential utililty inassessing and treating BED, but no single measure provides a picture ofthis disorder that is both comprehensive and detailed. The Questionnaireof Eating and Weight Patterns, for example, is preferable for diagnosticpurposes because it derives directly from BED criteria. However, informa-tion on psychological correlates of the disorder must be obtained frominstruments such as the Eating Disorder Inventory-2, Three-Factor EatingQuestionnaire, and Restraint Scale. In a similar way, the Binge Scale andthe Binge Eating Scale provide multifaceted measures of binge severity, yetlack the Questionnaire of Eating and Weight Patterns capacity to measurebinge frequency. In the interest of obtaining comprehensive information,several measures are justified, particularly given the nascent state of BEDassessment.

    Self-MonitoringSelf-monitoring has long been a mainstay in assessing eating behavior

    in obesity (Bellack, 1976) and bulimia nervosa (Schlundt, Johnson, &Jarrell, 1986). The procedure typically involves recording eating episodesand their situational contexts. A primary advantage of self-monitoring isthe direct measurement of eating episodes, which theoretically reduces thepotential for distortion relative to recall-based methods such as question-naires and interviews. Self-monitoring can also elicit the comprehensiveinformation required for abstracting functional relationships between sit-uational events and eating behavior (Schlundt et al., 1986). Given theseadvantages, it is not surprising that self-monitoring has been appliedto such diverse topics as treatment outcome (e.g., Agras, Schneider, Ar-now, Raeburn, & Telch, 1989; Leitenberg, Rosen, Gross, Nudelman, &Vara, 1988), binge characteristics (Rossiter et al., 1992), mood correlates

    ASSESSMENT AND TREATMENT OF BINGE EATING DISORDER I

  • 5/27/2018 binge eating disorder

    12/23

    (Lingswiler, Crowther, Stephens, 1987), and energy intake (Yanovski &Sebring, 1994) in populations spanning the range of eating disorders.

    Although the potential reactivity of self-monitoring procedures is rec-ognized (e.g., Wilson, 1987), several studies comparing subjects and otherobservers support the validity of self-monitoring as an assessment method.Crowther, Lingswiler, and Stephens 1984), for example, found excellentagreement between subjects and their partners for both the type (86.4 )and quantity (90.3 ) of food consumed during eating episodes. No differ-ences were found between partner-present and partner-absent meals, sug-gesting that significant reactivity did not occur. Self-monitored binging alsohas been shown to vary with diagnostic classification based on the Ques-tionnaire of Eating and Weight Patterns (Nangle et al., 1994). In this latterstudy, a comparison of self-monitoring over a 3-week period wi th the ques-tionnaire revealed a significant relationship between diagnostic categoriesand the recorded frequency of binge eating.

    One factor ensuring the continued use of self-monitoring in eatingdisorders research is i ts amenability to functional analysis (Johnson et al.,1995; Schlundt, 1989; Schlundt, Johnson, & Jarrell, 1985, 1986). Recentfindings suggest important similarities and differences between subjects di-agnosed w i th BED and both nonclinical binge eaters and normal controls(Johnson et al., 1995). Future research using self-monitoring may elucidatesimilar differences between BED and other eating-disordered populations.A second factor ensuring the continued utility of self-monitoring concernsthe diagnostic criteria for BED. Unlike anorexia nervosa, in which thediagnostic criteria are largely attitudinal and nonepisodic in nature, thecriteria for BED (particularly Criteria A, B, and D-see Exhibit 1 ) requiredetailed information on binge frequency, size, physical and social antece-dents, and associated emotions-the very characteristics self-monitoringdata are suited to illuminate.

    Several caveats can be offered with respect to self-monitoring. First,in constructing self-monitoring forms, the advantages of detail must beweighed against the potential aversiveness of recording demands. Ideally,self-monitoring provides information on time, physical location, type andquantity of food or drink, social and emotional context, and perception ofamount consumed for any eating or drinking episode. Excessively demand-ing forms may compromise the validity of self-monitoring by encouragingsubjects to respond carelessly rather than accurately in an effort to com-plete the recording process. Second, providing subjects with explicit in-structions not to alter their eating habits (e.g., Johnson et al., 1995) mayreduce the potential for reactivity. Third, subjects should receive precisetraining in self-monitoring to ensure that subject and experimenter sharean understanding of the information the self-monitoring system is designedto elicit.332 JOHNSON A N D TORGRUD

  • 5/27/2018 binge eating disorder

    13/23

    InterviewOf the interview formats that address binge eating (see Wilson, 1993,

    p. 234), the Eating Disorder Examination (Cooper & Fairburn, 1987; seechapter 9, this volume) is used most widely. Unfortunately, while this ex-amination has been employed extensively in the study of bulimia nervosa(e.g., Wilson, Eldredge, Smith, & Niles, 1991; Wilson & Smith, 1989),data are scarce on individuals with BED and pre-BED diagnoses. Existingdata suggest differences between pre-BED and normal weight bulimic pa-tients on the restraint subscale (Marcus et al., 1992; Wilson & Smith,1989). In addition, Wilson, Nonas, and Rosenblum (1993) demonstratedthat 16 items from a questionnaire version of the Eating Disorder Exami-nation discriminated obese binge eaters from nonbinge eaters. The largestt values were for items targeting preoccupation with weight and concernabout being seen eating.An interesting aspect of the Eating Disorder Examination is itsuse of DSM-IV definitions for large amount of food and loss of con-trol to categorize overeating episodes. As shown in Figure 1,

    Amount eatenLarge

    (EDE definition)Not large,but

    viewed by subjectas excessive

    Lossof

    control

    Nolossofcontrol

    Objectivebulimicepisodes

    Objectiveovereating

    Subjectivebulimicepisodes

    Subjectiveovereating

    igure 1. The Eating Disorder Examination scheme for classifying episodes ofovereating. From Fairburn and Wilson (1993).

    ASSESSMENT AND TREATME NT OF BINGE EATING DISORDER

    two

  • 5/27/2018 binge eating disorder

    14/23

    dimensions-namely, perceived loss of control and amount eaten-areused to define a four-fold classification of eating episodes. Unfortunately,use of the DSM-IV definition of binge imports into the examination con-ceptual scheme the problems of classification mentioned earlier: How muchfood is definitely larger than most people would eat in similar circum-stances?A number of subjective elements pervade this supposedly objectivecriterion (e.g., definitely larger, most people, and similar circumstances) allow-ing so-called objective bulimic episodes and objective overeating to becomepersonal judgments of the interviewer. An additional concern is raised bythe variable size of eating episodes identified by subjects as binges (Rossiter& Agras, 1990; Rossiter et al., 1992) and by the poor agreement betweenbingers and judges about the status (i.e., binge vs. nonbinge) of the bingersown eating episodes (Johnson et al., 1993). These data suggest that theexperience of bingeing may be so tied to subjective variables such as lossof control and the violation of internal dietary standards (Schlundt &Johnson, 1990, pp. 77-91) that any objective definition may be of ques-tionable utility. This having been said, the depth and breadth of infor-mation generated by the Eating Disorder Examination makes it particularlysuitable for the study of BED. Detailed information will become increas-ingly important as new and subtle diagnostic distinctions continue toemerge.Assessment: Summary and Recommendations

    Data obtained from questionnaires, self-monitoring, and interviews allmay contribute to the assessment of patients with BED. Questionnairesand interviews provide diagnostic and clinically relevant information,whereas self-monitoring measures the severity, change, and associated var-iables. Future research should determine which measures best reflect thecore symptoms of the BED diagnosis and are sensitive to changes producedby interventions.

    TREATMENT OF BINGE EATING DISORDERTh e treatment of BED has focused on two separate yet complimentary

    objectives-namely, weight management and a reduction in binge eating.Since the majority of patients meeting BED criteria are obese, treatmentefforts directed at weight control are indicated, and they typically involvecomprehensive cognitive-behavioral programs that attempt to modify dis-ordered eating behaviors, among others. Also, wi th the recognition of bingeeating per se as a clinical problem, other treatment interventions have beendirected almost exclusively toward controlling eating behavior. Although

    334 J O H N S O N ND TORGRUD

  • 5/27/2018 binge eating disorder

    15/23

    these two treatment objectives and their interventions are interrelated, forthe most part, the literature has addressed them separately.Weight Management

    In contrast to early evidence (Keefe et al., 1984), more recent findingsshow that BED and pre-BED individuals appear to lose as much weight asnonbingers over the course of behavioral weight control programs (LaPorte,1992; Marcus et al., 1988). In some cases, these losses are quite significant(Wadden, Foster, & Letizia, 1992). Drop-out and maintenance may bemore problematic. For example, both drop-out and relapse rates are higherfor obese individuals with BED than those without BED (Keefe et al., 1984;Marcus et al., 1988; Yanovski, 1993). Marcus et al. (1988) employed BingeEating Scale scores and DSM-III criteria to divide obese subjects into bingeeating and nonbinge eating groups. Subsequently, subjects participated ineither a standard weight control program o r one modified for binge eating.While the treatments were not differentially effective, the binge eaters weremore likely to drop out of treatment and regained significantly more weightat 6-month follow-up than nonbinge eaters.Managing Eating Behavior

    Both pharmacological and psychotherapeutic interventions have beenevaluated for the management of eating behavior, and the results are largelyconsistent with those of weight control studies in demonstrating difficultyin adherring to interventions, as well as higher drop-out and relapse rates.Pharmacological treatments have relied primarily on antidepressants, anddesipramine and imipramine have been shown to reduce the frequency andthe duration of binge eating, respectively, in pre-BED obese subjects.McCann and Agras (1990), for example, randomly assigned women diag-nosed with DSM-III-R bulimia nervosa who did not regularly purge toeither a desipramine treatment or a placebo control group. By week 12 ofthe trial, subjects treated with desipramine reduced their binge frequencyby 63 , compared to a 16% increase for control subjects. Binge frequencyapproached baseline rates following medication withdrawal, suggesting thateither the act of taking medication or some aspect of the drug was respon-sible for the reduction in binge frequency.

    As with weight control, psychotherapy for the management of eatingbehavior involves a number of cognitive-behavior therapy interventionsthat are designed to establish regular eating patterns. These interventionsinclude self-monitoring, exposure to forbidden foods, challenging dysfunc-tional beliefs about eating, and training in relapse prevention. The responseto these interventions shows a similar pattern, with clinical improvement

    ASSESSMENT AND TREA TMENT OF BINGE EATING DISORDER 335

  • 5/27/2018 binge eating disorder

    16/23

    followed by relapse-although the extent of relapse is relatively small com-pared to that observed following pharmacotherapy termination (McCann& Agras, 1990). Telch, Agras, Rossiter, Wilfley, and Kenardy (1990) eval-uated cognitive-behavioral therapy for binge eating and found reductionsin binge frequency of 94 for nonpurging bulimics compared to 9 in acontrol group, with many of the treated subjects eliminating binge eatingentirely. Although relapse was significant-only 46% of subjects remainedbinge-abstinent at 10-week follow-up-binge frequency remained signifi-cantly improved over baseline levels. Similar binge frequency changes wereobtained by Wilfley et al. 1993),who found comparable treatment efficacyfor cognitive-behavioral therapy and interpersonal psychotherapy.Treatment for Binge Eating Disorder: Summary and Recommendations

    In light of the existing data on the characteristics of individualswi t h BED, it is obvious that treatment should be directed at the dis-ordered eating and associated psychopathology. Most prominent in thisregard are binge eating and its antecedents-nutrition, body image dissat-isfaction, and depression. The interrelated nature of these symptoms in-dicates that improvement on one target such as weight reduction may yieldpositive changes in another. For example, depressed mood is usually ele-vated with weight loss. However, in a practical, programmatic sense, theidiosyncratic nature of these relationships for specific subjects appears torequire a comprehensive program, and the available literature supportsthese inclusive efforts.

    Current cognitive-behavioral therapy programs reduce binge eatingduring implementation (Smith et al., 1992; Wilfley et al., 1993), however,the poor maintenance of these reductions (e.g., Telch et al., 1990) suggeststhat further efforts at relapse prevention are needed. A fruitful avenue forpreventing relapse may be the treatment of clinical problems associatedwith BED, including psychopathology (Schmidt & Telch, 1990; William-son et al., 1990) and body size dissatisfaction (de Zwaan et al., 1994).Interventions directed at the psychopathology associated with BED couldreduce the influence of emotional cues on binge eating (Johnson et al.,1995), and antidepressant medications may be helpful in combination w i t hcognitive-behavioral therapy (Alger, Schwalberg, Bigaouette, Michalek, &Howard, 1991; McCann & Agras, 1990). Treatment of body size dissatis-faction, either through modification of self-evaluative assumptions (Smithet al., 1992) or weight reduction (Wadden et al., 1992), may attenuate thetendency for individuals treated only for bingeing to engage in self-imposeddieting, a practice that could contribute to future binge eating (Telch &Agras, 1993; Telch et al., 1990). Consistent w i t h this notion, there isevidence that weight loss may reduce binge eating severity in subjects w i thBED (Yanovski 6r Sebring, 1994). In summary, the available data strongly336 JOHNSON AND TORGRUD

  • 5/27/2018 binge eating disorder

    17/23

    suggest that the effective treatment of BED requires the management ofclinical features beyond those defined solely by its formal criteria.

    Although comprehensive interventions may increase the efficacy ofcurrent treatments for BED, these developments in treatment should becomplemented with efforts at prevention to reduce the prevalence of thisdisorder. In their recent multisite study, Spitzer et al. (1993) found that,among individuals enrolled in weight control programs, those diagnosedwith BED reported an earlier onset of both overweight and dieting thandid those without the diagnosis. These data underscore the necessity ofearly intervention and suggest that child and adolescent weight manage-ment programs that deemphasize dieting and weight per se, and at the sametime promote nutritional, activity, and lifestyle changes, may play an im-portant prophylactic role with respect to BED (chapter 12, this volume).

    Several questions regarding future developments in BED are indicatedfrom the foregoing review. In spite of its apparent simplicity, the natureand origin of binge eating is still fraught with more than a modicum ofuncertainty. As we have discussed, the definition of a binge is ambiguousbecause it relies on quantity and temporal criteria that are suspect andinconsistent w i th empirical data. Equally important is research on the de-velopment of binge eating in children, as there is compelling evidence thatBED is associated w i t h early onset of both overweight and dieting (Brodyet al., 1994; de Zwaan et al., 1992; Spitzer et al., 1993).

    REFERENCESAgras, W. S., Schneider, J . A., Arnow, B., Raeburn, S. D., & Telch, C. (1989).

    Cognitive-behavioral and response-prevention treatments for bulimia ner-vosa. Journal of Consulting and Clinical Psychology, 57, 2 15-22 1.

    Alger, S. A., Schwalberg, M. D., Bigaouette, J . M., Michalek, A. V., & Howard,L. J . (1991). Effect of a tricyclic antidepressant and opiate antagonist onbinge-eating behavior in normoweight bulimic and obese, binge-eating sub-jects. American Journal of Clinical Nutrition, 53, 865-87 1.

    American Psychiatric Association. 1980). Diagnostic and statistical manual of mentaldisorders (3rd ed.). Washington, DC: uthor.American Psychiatric Association. 1987). Diagnostic and statistical manua l of mental

    disorders (3rd ed., rev.). Washington, DC: Author.American Psychiatric Association. (1994). Diagnostic and statistical manua l of mental

    disorders (4th ed.). Washington, DC: Author.Antony, M. M., Johnson, W. G., Carr-Nangle, R. E., & Abel, J . (1994). Psycho-

    pathology correlates of binge eating and binge eating disorder. ComprehensivePsychiatry, 35, 386-392.

    Amow, B., Kenardy, J., & Agras, W. S. (1992). Binge eating among the obese: Adescriptive study. Journ al of Behavioral Medicine, 15, 155-1 70.ASSESSMENT AND TREATMEN T OF BINGE EATING DISORDER 337

  • 5/27/2018 binge eating disorder

    18/23

    Beglin, S. J., & Fairburn, C. G. (199 2). W ha t is meant by th e term binge?Bellack, A. S. (19 76). A comparison of self-reinforcement and self-monitoring in

    Brody, M. L., Walsh, B. T., & Devlin, M. J . (19 94 ). Binge eating disorder: Reli-ability and validity of a new diagnostic category. Journal of Consulting andClinical Psychology, 62 , 381-386.

    Cooper, Z., Cooper, P. J . & Fairburn, C. G . (1 98 9). T he validity of the EatingDisorder Examination and its subscales. British Journal of Psychiatry, 54,

    American Journal of Psychiatry, 149, 123-1 24.a weight reduction program. Behavior Therapy, 7, 68-75.

    807-812.Cooper, Z., & Fairburn, C. G. (198 7). T h e Eating Disorder Examination: A semi-structured interview for the assessment of the specific psychopathology ofeating disorders. lnterna tiona l Journ al of Eating Disorders, 6, 1-8.Crowther, J . H., & Chernyk, B. (1986). Bulimia and binge eating in adolescentfemales: A comparison. Addictive B ehaviors, I 1, 415-424.Crowther, J . H., Lingswiler, V. M., & Stephens, M. A . P. (19 84). The topographyof binge eating. Addictive B ehaviors, 9, 299-303.DaCosta, M., . Halmi, K. A . (1992). Classification of anorexia nervosa: Question

    of subtypes. lnterna tiona l Journ al of Eating Disorders, 1 I 305-313.de Zwaan, M., Mitchell, J . E., Seim, H. C., Specker, S. M., Pyle, R. L., Raymond,N. C., & Crosby, R. B. (1 99 4) . Eating related a nd general psychopathology

    in obese females with binge eating disorder. lnterna tiona l Journ al of EatingDisorders, 15, 43-52.

    de Z waan, M., Mitchell, J . E., Specker, S. M., Pyle, R. L., Mussell, M. l?, & Seim,H. C. (1 99 3). Diagnosing binge eating disorder: Level of agreement betweenself-report and expert rating. International Journal of Eating Disorders, 14,289-295.

    de Zwaan, M., Nutzinger, D. O., & Schoenbeck, G . (199 2). Binge eating in over-weight women. Comprehensive Psychiatry, 3 3, 256-261.Fairburn, C. G., Jones, R., rev eler, R. C., Carr, S. J . Solomon, R. A., OConnor,M. E., Burton, J. & Hope, R. A. (19 91) . Th ree psychological treatments forbulimia nervosa: A comparative trial. Archives of General Psychiatry, 48,Fairburn, C. G., W elch, S. L., & Hay, P. J. (1 99 3). Th e classification of recurrentovereating: T he binge eating disorder proposal. International Journal of Eating

    Disorders, 13, 155-159.Fairburn, C. G., & Wilson, G. T. (1993). Binge eating: Definition and classifica-

    tion. In C. G. Fairburn 6 G. T. Wilson (Eds.), Binge eating: Nature, assess-ment, and treatment (pp. 3-14). New York: Guilford Press.

    Fichter, M. M., Quadflieg, N., & Brandl, B. (1993). Recurrent overeating: Anempirical comparison of binge eating disorder, bulimia nervosa, and obesity.International Journal of Eating Disorders, I 4 , 1 6.

    463-469.

    338 .lOHNSON ND TORGRUD

  • 5/27/2018 binge eating disorder

    19/23

    Fitzgibbon, M. L., & Kirschenbaum, D. S. (199 0). Heterogeneity of clinical pre-sentation among obese individuals seeking treatment. Addictive Behaviors, 15,29 1-295.Ganley, R. M. ( 19 88 ). Emotional eating and how it relates to dietary restraint,disinhibition, and perceived hunger. International Journal of Eating Disorders,7, 635-647.Garfinkel, P. E., Moldofsky, H. , & Garner, D. M. (1980). The heterogeneity ofanorexia nervosa. Archives of General Psychiatry, 37, 1036- 1040.Garner, D. M . (19 91). Eating Disorder Inventory-2. Odessa, FL: Psychological As-sessment Resources.Garner, D. M., Olmsted, M. P., & Polivy, J . (19 83 ). Development and validation

    of a m ultidimensional eating disorder inventory for anorexia nervosa a nd b u-limia. International Journa l of Eating Disorders, 2, 15-34.Garner, D. M., & Wooley, S. C. (1991). Confronting th e failure of behavioral and

    dietary trea tm en ts for obesity. Clinical Psychology Review, I I 729-780.Goldfein, J. A., Walsh, B. T., Lachaussee, J . L., Kissileff, H. R., & Devlin, M. J .1993). Eating behavior in binge eating disorder. InternationalJournal of EatingDisorders, 14, 427-43 1.Gormally, I. Black, S., Daston, S., & Rardin, D. (19 82 ). T h e assessment of binge

    eating severity among obese persons. Addictive Behaviors, 7, 47-55.Halmi, K . A., Falk, J . R., & Schwartz, E. (19 81 ). Binge-eating and vomiting: Asurvey of a college population. Psychological Medicine, I 697-706.Hawkins, R. C., & Clement, P. (198 0). Development and construct validation of

    a self-report measure of binge eating tendencies. Addictive Behaviors, 5,219-226.Heatherton, T. E, Polivy, J. King, G. A., & McGree, S. T. (1988) . The(Mis)measurement of restraint: An analysis of conceptual and psychometricissues. Journal of Abnormal Psychology, 97, 19-28.Heatherton, T. F., Polivy, J . & Herman, C. P. ( 19 89 ). Restraint and in terna lresponsiveness: Effects of placebo manipulations of hunger state on eating.Journal of Abnormal Psychology, 98, 89-92.Herman, C. P., & Mack, D. (1975). Restrained and unrestrained eating. Journal of

    Personality, 43, 647-660.Johnson, W. G., Carr, R. E., Zayfert, C., Nan gle, D. W., & Antony, M. (1993,November). What is binge eating A comparison of binge eater, peer, and professional judgments. Paper presented at the annual m eeting of the Association forAdvancement of Behavior T herapy Convention, Atlanta, G A.Johnson, W. G., Corrigan, S. A., Crusco, A. H., & Schlundt, D. G . (1986). Re-

    straint among bulimic women. Addictive Behaviors, I 35 1-354.John son , W. G., Schlun dt, D. G., Barclay, D. R., Ca rr-Na ng le, R. E., & Engler, L.E. (1 99 5) . A naturalistic functional analysis of binge eating. Behavior Therapy,26, 101-118.

    ASSESSMENT AND TREATMENT OF BINGE EATING DlSORDER 339

  • 5/27/2018 binge eating disorder

    20/23

    Katzman, M. A., & Wolchik, S. A. (1984). Bulimia and binge eating in collegewomen: A comparison of personality and behavioral characteristics. Journalof Consulting and Clinical Psychology, 52 , 423-428.

    Keefe, P. H., Wyshogrod, D., Weinberger, E., & Agras, W. S. (198 4). Binge eatingand outcome of behavioral treatment of obesity: A preliminary report. Be-haviour Research and Therapy, 22, 319-321.

    Kirkley, B. G., Kolotkin, R. L., Hernandez, J. T., & Gallagher, P. N. (1992). Acomparison of binge-purgers, obese binge eaters, and obese non-binge eaterso n the MM PI. International Journal of Eating Disorders, 12, 22 1-228.Kolotkin, R. L., Revis, E. S., Kirkley, B. G., & Janic k, L. (1 98 7) . Binge eating inobesity: Associated MMPI characteristics. Journal of Consulting and Clinical

    Psychology, 55, 872-876.Kuehnel, R. H., & Wadden, T. A. (1994). Binge eating disorder, weight cycling,and psychopathology. International Journal of Eating Disorders, 15, 321 -329.LaPorte, D. J . (199 2). Treatment response in obese binge eaters: Preliminary resultsusing a very low calorie diet (V LC D) and behavior therapy. Addictive Behav-

    iors, 17, 247-257.Leitenberg, H., Rosen, J., Gross, J . Nudelman, S., & Vara, L. (1 98 8) . Exposure

    plus response-prevention treatment of bulimia nervosa. Journal of Consultingan d Clinical Psychology, 56 , 535-541.

    Lingswiler, V. M ., Crow ther , .J. H., & Stephens, M. A. P. (19 87). Emotional reac-tivity and eating in binge eating and obesity. Journal of Behavioral M edicine,10, 287-299.

    Loro, A. D., & Orleans, C. S. (1 98 1) . Binge eating in obesity: Preliminary findingsand guidelines for behavioral analysis and treatment. Addictive Behaviors, 6 ,155-166.Lowe, M. R. (1 992 ). Staying on versus going off a diet: Effects on eating in normalweight and overweight individuals. International Journal of Eating Disorders, 12,41 7-424.Lowe, M. R. (199 3). Th e effects of dieting on eating behavior: A three-factormodel. Psychological Bulletin, I 14, 100- 12 1.Lowe, M. R., & Caputo, G . C. (19 91). Binge eating in obesity: Toward the spec-

    ification of predictors. International Journal of Eating Disorders, 10, 49-55.Marcus, M. D., Smith, D., Santelli, R., & Kaye, W. (1992). Characterization of

    eating disordered behavio r in obese binge eaters. International Journal of EatingDisorders, 12, 249-255.

    Marcus, M. D., Wing, R. R., Ewing, L., Kern, E., Gooding, W, & McDermott, M.(1990a). Psychiatric disorders among obese binge eaters. International Journalof Eating Disorders, 9, 69-77.

    Marcus, M. D., Wing, R. R., Ewing, L., Kern, E., McDermott, M., & Gooding,W. (199 0b) . A double-blind, placebo-controlled trial of fluoxetine plus be-havior modification in the treatment of obese binge-eaters and non-bingeeaters. American Journal of Psychiatry, 147, 876-881.

    34 IOHNSON AND TORGRUD

  • 5/27/2018 binge eating disorder

    21/23

    Marcus, M. D., Wing, R. R., & Hopkins, J . (1988). Obese binge eaters: Affect,cognitions, and response to behavioral weight control. Journal of Consultingand Clinica l Psychology, 56 , 433-439.

    McCann, U. D., & Agras, W. S. (1990). Successful treatment of nonpurging bu-limia nervosa with desipramine: A double-blind, placebo-controlled study.American Journal of Psychiatry, 147, 1509-1513.

    McCann, U. D., Rossiter, E. M., King, R. J., & Agras, W. S. (199 1). Nonpurgingbulimia: A distinct subtype of bulimia nervosa. International Journal of EatingDisorders, 0, 679-687.

    Nangle, D. W., Johnson, W. G., Carr-Nangle, R. E., & Engler, L. E. (1994). Bingeeating disorder and the proposed DSM-IV criteria: Psychometric analysis ofthe Questionnaire of Eating an d Weight Patterns. International Journal of Eat-ing Disorders, 16, 147-157.

    Prather, R. C., & Williamson, D. A. (1988). Psychopathology associated withbulimia, binge eating, and obesity. International Journal of Eating Disorders, 7,177-184.

    Rossiter, E. M., & Agras, W. S. (199 0). An empirical test of the DSM-III-R def-inition of binge. International Journal of Eating Disorders, 9, 5 13-518.

    Rossiter, E. M., Agras, W. S., Telch, C. F., & Bruce, B. (1992). The eating patternsof nonpurging bulimic subjects. International Journal of Eating Disorders, I111-1 20.

    Ruderman, A. J . (19 85 ). Restraint, obesity and bulimia. Behaviour Research andTherapy, 23, 151-156.

    Ruderman, A. J . (1986). Dietary restraint: A theoretical and empirical review.Psychological Bulktin, 99, 247-262.

    Schlund t, D. G . (1989). Assessment of eating behavior in bulimia nervosa: Theself-monitoring analysis system. In W. G. Johnson (E d.) , Advances in eatingdisorders V ol. pp. 1-41). New York: JAI Press.

    Schlund t, D. G., & John son , W. G. (1990). Eating disorders: Assessment and treat-ment. Boston: Allyn & Bacon.

    Sch lund t, D. G., Joh nso n, W. G., & Jarrell, M. P. (19 85 ). A naturalistic functionalanalysis of eating behavior in bulimia and obesity. Advances in Behavior Re-search and Therapy, 7, 149-162.

    Schlund t, D. G., John son , W. G., & Jarrell, M. P. (19 86). A sequen tial analysisof env iron me ntal, behavioral, and affective variables predictive of vomitingin bulimia nervosa. Behavioral Assessm ent, 8, 253-269.

    Schmidt, N. B., & Telch, M. J. (199 0). Prevalence of personality disorders amongbulimics, non-bulimic binge eaters, and normal controls. Journal of Psycho-pathology and Behavioral Assessment, 12, 169- 185.

    Sm ith , D. E., Marcus, M. D., & Kaye, W. (19 92 ). Cognitive-behavioral treatmentof obese binge eaters. International Journal of Eating Disorders, 12, 257-262.

    Smith, M. C., & The len, M. H. (1984 ). Development an d validation of a test forbulimia. Journal of Consulting and Clinical Psychology, 52, 863-872.ASSESSMENT AND TR EATME NT OF BINGE EATING DISORDER 4 1

  • 5/27/2018 binge eating disorder

    22/23

    Spitzer,R. L., Devlin, M., Walsh, B. T., Hasin, D., Wing, R., Marcus, M., Stunk ard,A., Wadden, T., Yanovski, S., Agras, S. itchell, J., & Nonas, C. (1991).Binge eating disorder: To be or not to be in DSM-IV. International Journal ofEating Disorders, 10, 627-629.

    Spitzer, R. L., D evlin, M ., Walsh , B. T., Hasin, D., Wing, R., Marcus, M., Stunkard,A., Wadden, T., Yanovski, S. gras, S. itchell, I. & Nonas, C. (1992).Binge eating disorder: A multisite field trial of the diagnostic criteria. Inter-national Journal of Eating Disorders, 1 I , 19 1-203.

    Spitzer, R. L., Yanovski, S., Wadden, T., Wing, R., Marcus, M., Stunkard, A.,Devlin, M., Mitchell, J., Hasin, D., & Horne, R. L. (1993). Binge eatingdisorder: Its further validation in a multisite study. International Journal ofEating Disorders, 13, 137-153.

    Stunkard, A. J . (1959). Eating patterns and obesity. Psychiatry Quarterly, 33,284-295.Stunkard, A. J., & Messick, S. (1985). Th e Three-Factor Eating Questionnaire tomeasure dietary restraint, disinhibition and hunger. Journal of Psychosomatic

    Research, 29, 7 1-83.Telch, C. F., & Agras, W. S. 1993). T he effects of a very low calorie diet on bingeeating. Behavior Therapy, 24, 177-193.Telch, C. F., & Agras, W. S. (1994). Obesity, binge eating, and psychopathology:Are they related? International Journal of Eating Disorders, 15, 53-61.Telch, C. F., Agras, W. S., & Rossiter, E. M. (1988). Binge-eating increases withincreasing adiposity. International Journal of Eating Disorders, 7, 115-1 19.Telch, C. F., Agras, W. S., Rossiter, E. M., Wilfley, D., & Kenardy, J . (1990 ). Groupcognitive-behavioral treatment for the nonpurging bulimic: An initial eval-uation. Journal of Consulting and Clinical Psychology, 58, 629-635.Thelen, M. H., Farmer, J. Wonderlich, S., & Smith, M. (1991). A revision of theBulimia Test: Th e BULIT-R. Psychological Assessment: A Journal of Consulting

    an d Clinical Psychology, 3, 119-124.Van Strien, T., Frijters, J . E., Bergers, G. P. A., & Defares, P. B. (1986). DutchEating Behaviour Questionnaire for assessment of restrained, emotional andexternal eating behavior. International Journal of Eating Disorders, 5 , 295-3 15.Wadden, T. A., Foster, G. D., & Letizia, K. A. (1992) . Response of obese bingeeaters to treatment by behavior therapy combined with very low calorie diet.

    Journal of Consulting and Clinical Psychology, 60, 808-8 11.Walsh, B. T., Kissileff, H. R., Cassidy, S. M., & Dantzic, S. (1989). Eating behavior

    of women with bulimia. Archives of General Psychiatry, 46, 54-58.Wilfley, D. E., Agras, W. S., Telch, C. F., Rossiter, E. M., Schneider, J. A., Cole,A. B., Sifford, L., & Raeburn, S. D. (1993). Group cognitive-behavioraltherapy and group interpersonal psychotherapy for the nonpurging bulimicindividual: A controlled comparison. Journal of Consulting and Clinical Psy-

    chology, 61, 296-305.

    342 JOHNSON AND TORGRUD

  • 5/27/2018 binge eating disorder

    23/23

    Williamson, D. A., Cleaves, D. H., Savin, S. S. (1992). Empirical classificationof disorder not otherwise specified: Support for DSM-IV changes. Journal ofPsychopathology and Behavioral A ssessment, 14, 201-2 16.

    Williamson, D. A., Prather, R. C., McKenzie, S. I. & Blouin, D. C. (1990).Behavioral assessment procedures can differentiate bulimia nervosa, compul-sive overeater, obese, and normal subjects. Behavioral Assessment, 12, 239-252.

    Wilson, G. T. (1987). Assessing treatment outcome in bulimia nervosa: A meth-odological note. International Journal of Eating Disorders, 6, 339-348.Wilson, G . T. (1993). Assessment of binge eating. In C. G. Fairburn & G . T.Wilson (Eds.), Binge eating: Nature, assessment, and treatment (pp. 227-249).New York: Guilford Press.Wilson, G. T., Eldredge, K. L., Smith, D., & Niles, B. (1 99 1) . Cognitive-behavioural treatment with and without response prevention for bulimia. Be-

    hawiour Research and Therapy, 29, 575-583.Wilson, G. T., Nonas, C. A., & Rosenblum, G. D. (1993). Assessment of bingeeating in obese patients. International Journal of Eating Disorders, 13, 25-33.Wilson, G. T., & Smith, D. (198 9). Assessment of bulimia nervosa: An evaluationof the Eating Disorder Examination. International Journal of Eating Disorders,

    8, 173-179.Yanovski, S. 2 (1993). Binge eating disorder: Current knowledge and fu tu re di-rections. Obesity Research, 1 306-324.Yanovski, S. Z., Leet, M., Yanovski, J. A., Flood, M., Gold, P. W., Kissileff, H. R.,

    & Walsh, B. T. (199 2). Food selection and intake of obese women with bingeeating disorder. American Journal of Clinical N utrition, 56, 975-980.Yanovski, S. Z., & Sebring, N. G. (1994). Recorded food intake of obese womenwith binge eating disorder before and after weight loss. International Journal

    of Eating Disorders, 15, 135-150.

    ASSESSMENT AND TREATME NT OF BINGE EATING DISORDER 343