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Article history:
Received 13 December 2010
Received in revised form 9 June 2011
Accepted 7 July 2011
Keywords:
Ecological momentary assessment
Eating disorder
Binge eating
Mood
Emotion regulation
Antecedents
a b s t r a c t
Current explanatory models for binge eating in binge eating disorder (BED) mostly rely on models for bulimia
nervosa (BN), although research indicates different antecedents for binge eating in BED. This study
investigates antecedents and maintaining factors in terms of positive mood, negative mood and tension in a
sample of 22 women with BED using ecological momentary assessment over a 1-week. Values for negative
mood were higher and those for positive mood lower during binge days compared with non-binge days.
During binge days, negative mood and tension both strongly and signicantly increased and positive mood
strongly and signicantly decreased at the rst binge episode, followed by a slight though signicant, and
longer lasting decrease (negative mood, tension) or increase (positive mood) during a 4-h observation period
following binge eating. Binge eating in BED seems to be triggered by an immediate breakdown of emotion
regulation. There are no indications of an accumulation of negative mood triggering binge eating followed by
immediate reinforcing mechanisms in terms of substantial and stable improvement of mood as observed in
BN. These differences implicate a further specication of etiological models and could serve as a basis for
developing new treatment approaches for BED.
2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
The core feature of binge eating disorder (BED) comprises loss of
control and consumption of large amounts of food (American
Psychiatric Association (APA), 1994). Cognitive behavioral therapy
(CBT) approaches in BED are traditionally based on corresponding
models for bulimia nervosa (BN) and constitute the established
treatment for the majority of BED patients (Vocks et al., 2009). In BN,
negative mood has been shown to be an important antecedent by a
number of studies (Polivy et al., 1984; Agras and Telch, 1998; Waters et
al., 2001). According to the affect regulation model, individuals engage
in binge-purge behavior to alleviate negative mood (Polivy et al., 1984)
or by substitution of a less aversive mood state (trade off-theory,
Kenardy et al., 1996). Masking theory suggests that rather than
decreasing or substituting negative mood, binge eating serves as an
attribution for negative mood that masks other problems (Herman and
Polivy, 1988). In other words, negative affect can be blamed on binge
eating, which seems to be more controllable to the person than the
actual causes of distress. The escape theory (Heatherton and Baumeister, 1991) posits that binge eating represents an attempt to escape
from distressing self-awareness and to narrow attention to the
immediate physical surroundings or stimuli (e.g. food). As a secondary
effect, the hypothesized shift in awareness impedes higher level
Corresponding author at: University of Fribourg, Department of Psychology, 2, Rue
de Faucigny, CH-1700 Fribourg, Switzerland.
E-mail address: simone.munsch@unifr.ch (S. Munsch).
0165-1781/$ see front matter 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.psychres.2011.07.016
119
2.1. Participants
Data were collected from obese individuals with BED presenting for participation in
a treatment trial to evaluate the efcacy of a short version of a cognitive behavior
therapy (CBT) trial at the Department of Clinical Psychology and Psychotherapy of the
University of Basel (Switzerland) (Schlup et al., 2009). The study was approved by the
local ethics committee of the University Hospital of Basel. Inclusion criteria for the
clinical trial included being aged between 18 and 70 years, having a BMI between 27
and 40 kg/m2, being free from severe medical conditions such as diabetes, heart
disease, or endocrine disorders and meeting full DSM-IV-TR criteria for BED (American
120
German version by Feist and Stephan, 2007) developed for ambulatory assessment,
which contains ve empirically derived subscales: negative mood, positive mood,
interest, tension, and sleepiness. Feist and Stephan (2007) reported sufcient
correlations (r = 0.60) of the Negative Mood Subscale with the Beck Depression
Inventory (BDI, Beck et al., 1961; Hautzinger et al., 1995) and good testretest
reliability (r = 0.70) in a student sample. Based on clinical experience and literature on
mood in BED (Stickney and Miltenberger, 1999; Vanderlinden et al., 2001; Binford et al.,
2004; Engel et al., 2006; Smyth et al., 2007), we additionally included the following
adjectives in the electronic questionnaire: bored, stressed out, anxious, sad, tense,
lonely, and annoyed.
To combine the items of the MAI with the additional items, and to obtain a limited
number of reliable, valid and interpretable measures of mood, all items were entered
into an exploratory factor analysis using principal components as extraction and
varimax as rotation method. Items with loadings b 0.4 were excluded from further
analyses. Based on the Scree plot and the Kaiser criterion (excluding components with
Eigenvalues b 1.0), we obtained three different factors. These factors represent scale
scores, i.e., they were computed by taking the mean across all items which loaded
highly on them. The rst factor, which explained 10% of the variance, was highly
correlated with the MAI-scale negative mood (r = 0.92) and was given this label. It
contained the MAI items discontented, depressed, and queasy plus the additional items
bored, anxious, lonely, and sad. The second factor, which explained 39% of the variance
was highly correlated with the MAI scale tension (r = 0.94) and received this label. It
contained the MAI items calm, nervous, and agitated plus the additional items stressed
out, tense, and annoyed. The third factor, which explained 15% of the variance, was
highly correlated with the two MAI scales positive mood (r = 0.92) and interest
(r = 0.94) and was given the label positive mood. It contained the MAI items
cheerful/merry, good, and happy of the positive mood scale, and fascinated, interested,
and not interested of the MAI interest scale, with no additional items. Factor scores
based on these three factors were then used as mood-related variables in subsequent
analyses.
2.2.4. Situational context of binge eating
These were assessed by the two questions where are you at the moment? and
whom are you with?. Answers were recoded into the two variables being at
home/not at home and being alone/not alone.
2.2.5. Trait specic characteristics moderating the impact of mood and tension on binge
eating
To analyze the moderating impact of participants' characteristics related to eating
disorder and clinical features on temporal trends of positive or negative mood and
tension during binge days, we included the following baseline variables: comorbidity
status, baseline BMI, duration of BED (years since rst manifestation of BED), severity of
eating disorder pathology (measured by the global score, GS, of the EDE), and
depressiveness (measured by the BDI, Hautzinger, 1991).
2.3. Statistical analysis
We used a random intercept model to analyze the data (Pinheiro and Bates, 2000).
Random intercept models are special types of linear mixed models in which each
individual is assumed to have his/her own intercept. This kind of model is suitable for
cases where each subject follows his/her own time schedule (i.e. both the number of
time points and the time interval are allowed to vary from subject to subject) which is
often observed in EMA based studies. The distinction between binge days and nonbinge days was based on whether at least one daily binge episode occurred or not. For
the precise model equations, please refer to Appendix A.
Model 1 tested whether the daily course of mood factors differed between binge
and non-binge episodes while allowing for a trajectory following a linear and quadratic
polynomial.
Model 2 tested for temporal trends in the mood factors before and after the
occurrence of the rst daily binge. Hence we introduced an additional dummy variable
distinguishing between the pre- and post-binge phase during binge days that allowed
us to model the temporal trends of these two phases independently. This model
contained the interactions between time and each of the two dummy variables pre- and
post-binge phase. For the temporal trend during the pre-binge phase, we included
polynomials up to 5th degree as doing so improved model t. The inclusion of
polynomials higher than linear during the post-binge phase in contrast did not improve
model t and we therefore only used a linear trend (see Appendix A for the exact model
equation). The variable time was centered to the rst binge episode, separately for each
patient and day. For this analysis we used a subsample covering binge days only. We
omitted days starting with a binge episode as such cases could not have been analyzed
using Model 2 since there would have been no mood factor ratings preceding a binge
rating. This concerned 14 binge episodes stemming from 6 persons. We also omitted all
data points including and following the second binge episode within the same day as
the corresponding mood factor values might have been inuenced by the rst binge
episode. This concerned 16 binge episodes coming from 12 persons.
According to Smyth et al. (2007), we tested in Model 3 whether trends of values of
mood factors prior to the rst binge could still be observed after excluding the values at
the binge themselves. Thus in this model the values covering the 30 min immediately
prior to and the 30 min following the binge episode were excluded to prevent
recordings immediately associated with the binge event inuencing the model results.
For the temporal trend during both the pre- and post-binge phase, we included only
linear polynomials as polynomials of higher degree did not improve model t (see
Appendix A).
Finally, Model 4 tested whether BMI, EDE global score, comorbidity status (y/n),
number of years since rst manifestation of BED, and depressiveness (BDI) moderated
the temporal trends of negative mood, positive mood, and tension before and after the
rst daily binge as assessed in Model 2. This model therefore included in addition to the
terms listed in Model 2 the moderator (main effect) plus the interaction between
moderator and time for the pre- and post-binge phase. Each moderator was tested in a
separate model.
Note that in all four models we did not include an individual random slope coefcient
b1i (Singer and Willett, 2003) as doing so would not have improved model ts. Mood
factors for negative mood and tension were both transformed logarithmically (natural) to
meet model assumptions. To analyze these models, we used the software SPSS 14.
Reported signicances are based on an alpha of 0.05 unless otherwise specied.
3. Results
Of the 28 patients, 6 never exhibited a binge during the entire
week and were excluded from all analyses. These six patients did not
differ from those reporting one or more binges during the study
period with respect to age, educational level, BMI, BDI, BAI, EDE total
score, rst manifestation of BED (years), and number of binge
episodes according to EDE (p N 0.05 for each t-test performed). For
the remaining 22 patients lling in the diary ve times a day during
the entire week, a total of 770 possible time-contingent data entries
were possible. They actually completed 651 records, corresponding to
a compliance rate of 85%. In addition, 36 event-contingent data entries
were recorded, resulting in a total of 687 data entries of which 75
(11%) concerned binge episodes. Each patient had on average 0.49
binge episodes per day.
Most binge episodes occurred in the afternoon (52%, 12:0018:00,
N = 39) and in the evening (39%, 18:0024:00, N = 29); very few
were observed during the night (4%, 24:0006:00, N = 3) and in the
morning (5%, 06:0012:00, N = 4). Models 2 and 4 covered only binge
days and thus included 198 records and Model 3 in addition excluded
all measurements within 30 min before and after a binge episode and
included 149 records.
3.1. Situational context of binge eating
The proportion of participants being at home rather than not at
home was 67% (N = 576) during non-binge periods, 83% (N = 29)
immediately before a binge episode and also 83% (N = 35) during a
binge episode. In the same way the proportion of participants being
alone rather than not alone was 46% (N = 576) during non-binge
periods, 72% (N = 29) immediately before a binge episode and 63%
(N = 35) during a binge episode.
3.2. Daily course of negative mood, positive mood, and tension (Table 1)
3.2.1. Model 1
Values for negative mood were signicantly higher during binge
than non-binge days without showing any particular daily trend
during either binge nor non-binge days. Values for positive mood
were signicantly lower during binge than non-binge days, especially
later during the day. However, no signicant daily trends could be
found. Values for tension did not vary between binge and non-binge
days but increased during the day until the afternoon and then
decreased again, both during binge and non-binge days.
3.2.2. Model 2
The average time period between the rst measurement in the
morning and the rst reported binge episode was 7.23 h (S.D. = 3.29).
For negative mood, there was a signicant curvilinear increase
immediately before the rst binge episode, with particularly high
rates of increase shortly before the rst binge (solid lines in Fig. 1a).
The linear post-binge trend was signicantly negative. Positive mood
121
Table 1
Daily course of negative mood, positive mood and tension. Regression coefcients for statistical models 13.
ln(negative
mood) 1000
(SE)
Model 1
Model 2
Model 3
ln(positive
mood) 1000
(SE)
t
8.74
4.48
tension 1000
t
(SE)
22.0
2.48
1073
57.3
2.64
2.09
5.32
0.02
0.36
1.04
6045 (275)
422 (170)
17.1 (15.1)
3.59 (3.00)
24.5 (23.4)
0.22 (1.19)
0.18
10.3 (4.05)
2.53
1.19 (1.26)
1379 (105)
950 (183)
13.1
5.19
4579 (355)
2319 (710)
12.9
3.26
1251 (119)
651 (182)
10.5
3.59
445 (102)
4.36
920 (396)
2.32
316 (101)
3.12
80.5 (20.5)
3.92
143 (79.5)
1.79
57.6 (20.3)
2.83
6.20 (1.71)
3.64
9.41 (6.61)
1.42
4.43 (1.69)
2.62
3.38
6.86
6.86
3.88
0.22 (0.19)
173 (62.8)
6472 (401)
1103 (512)
1.13
2.76**
16.2
2.15
0.17
55.0
785
533
(0.05)
(16.3)
(114)
(137)
26.0 (13.5)
47.1 (22.1)
1.93
2.14
103 (50.5)
50.1 (82.2)
1.14
1.19
1.05
2.04
0.61
0.12
38.3
867
308
(103)
(52.9)
(4.67)
(0.93)
(7.27)
10.7
1.08
0.56
2.25
905 (104)
223 (49.8)
0.1 (4.40)
0.28 (0.88)
7.12 (6.85)
(0.05)
(16.2)
(124)
(136)
22.1 (13.4)
25.3 (22.0)
0.46
0.95
2.44
2.37
6.97
2.26
1.65
1.15
p b 0.05.
p b 0.01.
p b 0.001.
4. Discussion
The present study is to our knowledge the rst to investigate daily
courses of mood and tension experienced during binge and non-binge
days and before and after binge eating, thereby covering an extended
time span in the natural environment of treatment-seeking women
with BED.
In general the study ndings corroborate ndings from studies on
BN and BED showing that negative mood ratings were higher and
positive mood ratings lower on binge days compared to non-binge
days (Smyth et al., 2007; Stein et al., 2007).
Considering binge days and temporal courses until the rst daily
binge, we found that positive mood, negative mood and tension all
strongly deteriorated immediately before the rst daily binge (see
Model 2), as has been observed in BN (Engelberg et al., 2007; Smyth
et al., 2007). It must be noted that in general and even during binge
eating values for mood factors, especially regarding negative mood
and tension, varied between 2.5 and 4 on a range of 1 to 10, which is
rather low (Fig. 1). Our analyses further revealed that the temporal
course of mood and tension was independent of eating disorder
severity or body weight. However, individuals suffering from
additional mental disorders were prone to higher increases in tension
shortly before the rst daily binge than individuals without comorbid
disorders. Also more depressed individuals experienced a lower
short-term increase of tension before the rst daily binge compared to
less depressed individuals.
Following the considerations of Smyth and colleagues, we
excluded the values covering the time span 30 min before and
30 min after the rst binge as these measures could be inuenced by
the affect-laden event of recent binge eating per se (Smyth et al.,
2007). In a BN sample, Smyth and colleagues found that even after
excluding these measures, accumulation of mood deterioration
remained a robust predictor of binge eating. In contrast, in our
sample of female BED individuals, excluding measures over the 1-h
interval resulted in a strikingly different pattern. We even observed a
slight improvement of mood up to 30 min before binge eating (Model
122
Fig. 1. Daily course of negative mood, positive mood, and tension before and after the rst binge episode. Values for negative mood and tension were backtransformed from lntransformation. Solid lines denote predicted values from linear mixed models during binge days and refer to statistical Model 2. Broken lines denote predicted values when disregarding
values at the time of the binge (30 min) and refer to statistical Model 3. Note that predicted values during non-binge days are not included. Grey lines denote means and 95% condencelimits of observed values and were obtained by computing means and condence limits of all observed values within dened time intervals. Intervals relative to the time variate centered at
the rst daily binge were: 6 h to 4 h/4 h to 2 h/2 h to b 0 h/time at rst daily binge/N 0 h to +2 h/+2 h to +4 h/+4 h to +6 h.
123
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