Available online at www.sciencedirect.

com

Comprehensive Psychiatry 53 (2012) 245 – 251

www.elsevier.com/locate/comppsych

Emotional eating in anorexia nervosa and bulimia nervosa

Valdo Riccaa,⁎, Giovanni Castellinia , Giulia Fioravantib , Carolina Lo Sauroa , Francesco Rotellaa ,
Claudia Ravaldia , Lisa Lazzerettia , Carlo Faravellib
a
Psychiatric Unit, Department of Neuropsychiatric Sciences, Florence University School of Medicine, 50134 Firenze, Italy
b
Department of Psychology, University of Florence, 50134, Firenze, Italy

Abstract

Objectives: The relationship between emotional states and eating behaviors is complex, and emotional eating has been identified as a
possible factor triggering binge eating in bulimia nervosa (BN) and binge eating disorder. Few studies considered emotional eating in patients
with anorexia nervosa.
Methods: The present study evaluated the clinical correlates of emotional eating in 251 eating-disordered (EDs) subjects (70 AN restricting
type, 71 AN binge eating/purging type, 110 BN purging type) and in a group of 89 healthy control subjects. Subjects were assessed by means
of a clinical interview (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) and several
self-reported questionnaires, including the Emotional Eating Scale (EES).
Results: No significant differences were found between the 3 EDs groups in terms of EES total score, and all patients with ED showed higher
EES scores compared with control subjects. Emotional eating was associated with subjective binge eating in AN binge eating/purging type
and with objective binge eating in patients with BN. Among patients with AN restricting type, emotional eating was associated with restraint,
but this association was lost when controlling for fear of loss of control over eating, which was the principal determinant of restraint.
Conclusion: Emotional eating and fear of loss of control over eating are significantly associated with specific eating attitudes and behaviors,
according to the different diagnoses. Emotional eating is a relevant psychopathologic dimension that deserves a careful investigation in both
anorectic and bulimic patients.
© 2012 Elsevier Inc. All rights reserved.

1. Introduction anger and loneliness, to cope with negative affect.” This

The relationship between emotional states and eating
behaviors is complex, and different studies showed that there
is a significant variability across individuals about the
emotion-induced changes of eating [1,2]. As far as negative
emotions are concerned, loss of appetite and reduction of
food intake have been considered physiological responses
[3,4], whereas an increase in food intake has been considered
an inappropriate response to distress [5]. Emotional eating
has been defined as “the tendency to eat in response to a
range of negative emotions such as anxiety, depression,
⁎ Corresponding author. Tel.: +39 055 7947487; fax: +39 055 7947487.
E-mail addresses: valdo.ricca@unifi.it (V. Ricca),
giovannicastellini78@hotmail.com (G. Castellini),
fioravantigiulia@libero.it (G. Fioravanti), carolina.losauro@libero.it
(C. Lo Sauro), docrot@gmail.com (F. Rotella), claudia.ravaldi@gmail.com
(C. Ravaldi), lisalazzeretti@alice.it (L. Lazzeretti), carlo.faravelli@unifi.it
(C. Faravelli).
0010-440X/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.comppsych.2011.04.062
construct is not merely focused on eating behavior and
overeating, but it specifically addresses the feelings that lead
people to experience an urge to eat and the desire of
assuming food in response to different emotions [6].
Emotional eating has been identified as a possible factor
triggering binge eating in bulimia nervosa (BN) [7] and
binge eating disorder (ED) [8-13], suggesting that episodes
of binge eating are often precipitated by stress and negative
affects [9] and that binge eating appears to be associated with
a subsequent decrease in negative affect [14,15]. However,
considering that affective regulation difficulty is a common
trait of EDs [16-18] and that patients with ED have high
levels of alexithymia [8,18], it is possible that emotional
eating plays a significant role also in anorexia nervosa (AN).
In fact, behaviors such as restricted food consumption, binge
eating, and compensatory behaviors are interpreted as
responses to regulate intense or relatively undifferentiated
emotional states, to restrict the affective experience or to
deviate attention from negative emotions [18].
246 V. Ricca et al. / Comprehensive Psychiatry 53 (2012) 245–251
To detect the relationships between emotional eating and
eating attitudes and behavior, the psychopathologic distinc-
tion between those patients who restrict food intake without
binging and purging (ie, anorectic restricting type) and
those who binge and purge is of interest [19]. In particular,
patients with ED perceive a relevant distress associated with
eating, which can be related to the fear of losing control
over eating even without experiencing an actual loss of
control, or to the feeling of the actual perceived loss of
control over eating, which in turn is judged a failure of the
personal dietary rules [20].
Moreover, the size of food eaten when patients perceive
the loss of control may be a useful tool to understand the
relationships between emotions and eating behaviors in
patients with ED. For instance, individuals with AN may feel
distressed and out of control when eating a small amount of
food exceeding their typical daily intake. The feeling of loss
of control may be associated with different sizes of food
eaten, because many patients with AN binge eating/purging
type (AN-B/P) can eat relatively small amount of food when
they reported they had a binge [21,22], whereas patients with
BN and binge ED can experience both objective and
subjective binge episodes [23-25]. It can be hypothesized
that the desire to eat, to cope with negative feelings, is not
associated only with the experience of overeating but also, or
mainly, with the fear of losing control over eating.
To the best of our knowledge, only 2 studies have
investigated emotional eating in anorectic patients [19,26],
reporting that patients with AN-B/P showed higher scores on
external eating and emotional eating, especially in response
to negative emotions, when compared with subjects with AN
restricting type (AN-R).
According to these observations and given the dearth
of studies on this topic, the aims of the present study
were as follows:
- To assess emotional eating in patients with restricting
(AN-R) and binging/purging (AN-B/P) AN and to
examine possible similarities or differences in patients
with BN.
- To evaluate the possible associations between emo-
tional eating and other psychopathologic variables in
anorectic and bulimic subjects.
2. Methods
2.1. Procedure
The study was conducted at the Outpatient Clinic for
Eating Disorders of the Psychiatric Unit of the University of
Florence, Italy. Participants were recruited from referrals by
family doctors and other clinicians. All the diagnostic
procedures and the psychometric tests are part of the routine
clinical assessment for patients with ED, performed at our
Clinic. Before the collection of data, during the first routine
visit, the procedures of the study were fully explained; after
that, patients were asked to provide their written informed
consent. The study protocol was approved by the ethics
committee of the institution.
2.2. Participants
All patients attending the Outpatient Clinic for Eating
Disorders between March 2003 and July 2005 were enrolled
in the study, provided they met the following inclusion
criteria: age between 18 and 60 years, diagnosis of AN
(restricting and binging purging subtypes) and BN binge-
purging type, assessed by means of the Structured Clinical
Interview for Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV) [27]. The exclusion
criteria were as follows: comorbid schizophrenia, illiteracy,
and mental retardation.
Five patients refused to participate in the study, and
8 patients were excluded because of the following reasons:
schizophrenia (3 patients), illiteracy (3 patients), and mental
retardation (2 patients). The final sample was composed of
251 subjects, 70 with AN-R, 71 with AN-B/P, and 110 with
BN binge-purging type.
The control group was enrolled according to the following
procedure: each control was extracted from the alphabetical
computerized list of clients of a general practitioner and was
selected as the first one fulfilling the inclusion criteria and
willing to participate. In the case of refusal, the next one on
the list, fitting the matching criteria, was asked to participate.
The control inclusion criteria were as follows: age between 18
and 60 years and body mass index ranging between 18 and
24.9 kg/m2. The exclusion criteria were the same of the
patients groups, plus the absence of any actual and lifetime
ED diagnosis, according to DSM-IV criteria, evaluated by
means of a face-to-face interview (Structured Clinical
Interview for DSM-IV [SCID-I]). Eight subjects were
excluded from the initial list of controls because of the
following reasons: refusal to give their informed consent (4),
illiteracy (3), and mental retardation (1). The final healthy
control group was composed of 89 subjects (3 men, or 3.3%)
with mean age of 28.66 ± 7.53 years.
2.3. Measures
The sociodemographic data, as well as the anthropometric
measures and the main organic comorbidities, were assessed
by a psychiatrist at the beginning of the visit.
Anthropometric measurements were made using stan-
dard calibrated instruments on the day of the psychopath-
ologic assessment.
To assess the diagnosis of AN and BN, patients were
interviewed by 2 expert clinicians (V.R. and G.C.), by means
of the SCID-I [27].
Objective binge episodes were defined as the consump-
tion of a large amount of food in a discrete episode, while
experiencing a sense of loss of control. Subjective binge
episodes were defined as the consumption of a not
 V. Ricca et al. / Comprehensive Psychiatry 53 (2012) 245–251
objectively large quantity of food in a discrete episode, while
experiencing a sense of loss of control [28,29].
The number of weekly objective binge eating and
subjective binge eating episodes, as well as the fear of
losing control over eating were evaluated by means of a face-
to-face clinical interview, according to specific questions
extracted from the Eating Disorder Examination Interview
(EDE 12.0D) [28], and from DSM-IV (Text Revision) [30].
The distinction between objective and subjective binge
eating was evaluated by means of the following questions:
“Different people mean different things by overeating. I
would like you to describe any time when you have felt that
you have eaten too much in one go” “During the considered
episodes, did you eat, in a discrete period of time (eg, within
any 2-hour period), an amount of food that is definitely
larger than most people would eat during a similar period of
time and under similar circumstances?” “Have there been
any time when you have felt that you have eaten too much,
but others might not agree?” The sense of loss of control over
eating was evaluated by means of the following specific
questions: “I would like to ask you about any episodes of
overeating that you may have had over the past 4 weeks”
“Did you have a sense of loss of control at that time?” “Could
you have stopped eating once you had started?” “Could you
have prevented the episode from occurring?”
Fear of losing control over eating was evaluated by
means of the following specific question: “Over the past 4
weeks have you been afraid of losing control over eating?”
The rate indicated the number of days on which definite
fear has been present, irrespective of whether the subject
feels to be in control.
Eating attitudes and behaviors were specifically investi-
gated by means of the Eating Disorder Examination
Questionnaire (EDE-Q) [31,32].
Emotional eating was assessed by means of the Emotional
Eating Scale (EES) [6], a 25-item self-report questionnaire that
indicates the extent to which specific feelings lead a subject to
feel an urge to eat. Each item consists of an emotion term (eg,
jittery, angry, helpless), and the 5-point scale used was
anchored on “no desire to eat” and “an overwhelming urge to
eat,” with “a small desire to eat,” “a moderate desire to eat,” and
“a strong desire to eat.” The 25 items form 3 subscales,
reflecting eating in response to anger (Anger/Frustration),
anxiety (Anxiety), and depressed mood (Depression). These 3
subscales refer to the emotional antecedents of binge eating,
and on each scale, higher scores reflect a greater tendency to
eat in response to emotional state. The EES has demonstrated
good internal consistency, construct validity, discriminant
validity, and criterion-related validity [6].
For a further characterization of the psychopathologic
features of the patients, the Beck Depression Inventory
(BDI) [33] and Spielberg State-Trait Anxiety Inventory
(STAI) [34] were also applied. Finally, patients were
evaluated by means of the Symptom Checklist (SCL
90-Revised) [35], a psychometric instrument devoted to
the identification of the psychopathologic distress.
247
2.4. Statistical analysis
One-way analysis of variance (ANOVA) was performed
to compare emotional eating, eating specific, and general
psychopathology between AN-R, AN-B/P, and BN groups.
Post hoc paired contrasts with Bonferroni correction were
conducted for the pairwise comparison among the groups.
The relationship between emotional eating and eating
psychopathology was preliminarily assessed by performing
Pearson bivariate correlations and then by using multiple
regression models.
Given that we performed multiple statistical tests, we set
the significance level to P b .01, representing a compromise
between the more stringent Bonferroni correction and the
exploratory nature of this study. All analyses were performed
using SPSS for Windows 17.0 (Chicago Inc, Chicago, IL).
3. Results
Descriptive statistics of the study variables for the 3
groups, together with ANOVA results, are reported in
Table 1. No significant differences were found between
AN-R, AN-B/P, and BN in EES total score. However, a
significant difference for emotional eating in response to
depression was found between patients with AN-R and
BN, with the latter showing higher levels.
Healthy control subjects showed significantly lower scores
in all the clinical variables taken into account compared with
patients with AN-R, AN-B/P, BN (all P b .001).
As far as general psychopathology is concerned, patients
with BN reported higher SCL-90 global score index and BDI
score compared with patients with AN-R and higher STAI
score compared with patients with AN-B/P.
Considering the eating behaviors, patients with BN
showed a higher frequency of objective binge eating
episodes compared with patients with AN-B/P, whereas
patients with AN-B/P reported more subjective binge
episodes than did patients with AN-R. Furthermore, patients
with BN and AN-B/P showed higher EDE-Q total and
subscale scores compared with patients with AN-R.
Significant bivariate correlations are shown in Table 2.
Emotional eating was found to be associated with different
eating behaviors according to the 3 diagnostic groups. In
particular, EES total score was positively correlated with
restraint in patients with AN-R, with subjective binge
episodes in patients with AN-B/P, and with the amount of
objective binge eating episodes in the BN group.
Moreover, the frequency of fear of loss of control over
eating episodes was found to be positively correlated with
emotional eating, only in the AN restricting group, and
with the assessed eating attitudes and behaviors, in all the
3 diagnostic groups.
Three multiple linear regression models were computed
for each EDs group, to test the effect of emotional eating
on different eating behaviors: the dependent variables were
248 V. Ricca et al. / Comprehensive Psychiatry 53 (2012) 245–251

Table 1
General characteristic of the sample
AN-R (n = 71) AN-B/P (n = 70) BN (n = 110) F Bonferroni post hoc (P) HC (n = 89)
AN-R vs AN-BP AN-R vs BN AN-BP vs BN
Female 68 (95.77%) 68 (97.14%) 108 (98.18%) 0.92 87 (97.7%)
Age (y) 26.46 ± 9.53 29.52 ± 10.64 30.25 ± 7.95 3.50 .17 .03 1.00 28.66 ± 7.57
BMI (kg/m2) 16.06 ± 1.70 16.34 ± 1.72 23.00 ± 6.67 57.57⁎ 1.00 b.001 b.001 16.06 ± 1.70
SCL-90 GSI 0.79 ± 0.92 1.05 ± 0.74 1.44 ± 0.66 5.88⁎ .29 .003 .59 0.59 ± 0. 44
BDI 14.48 ± 9.17 20.89 ± 11.13 23.03 ± 13.00 5.65⁎ .08 .003 1.00 5.34 ± 6.24
STAI 46.21 ± 27.66 32.68 ± 33.72 51.46 ± 51.46 4.14⁎ .20 1.00 .009 35 ± 10.45
EES TS 1.32 ± 1.01 1.56 ± 1.01 1.76 ± 1.03 2.86 .68 .05 .97 0.75 ± 0.69
EES Ang/Frust 1.21 ± 0.95 1.40 ± 1.02 1.70 ± 1.02 3.38 1.00 .03 .39 0.65 ± 0.71
EES Anx 1.39 ± 1.12 1.45 ± 0.97 1.60 ± 0.93 0.63 1.00 .82 1.00 0.75 ± 0.68
EES Dep 1.30 ± 0.98 1.70 ± 0.95 1.94 ± 1.08 5.69⁎ .009 .003 .74 1.07 ± .95
FLC 17.24 ± 11.49 17.66 ± 8.91 15.32 ± 9.20 0.35 1.00 .80 .45 17.24 ± 11.49
SBE 1.31 ± 1.74 7.21 ± 7.20 6.91 ± 7.15 10.55⁎ b.001 b.001 1.00 1.31 ± 1.74
OBE 7.47 ± 7.17 11.00 ± 6.27 17.09⁎ .009
EDE-Q TS 2.49 ± 1.44 3.58 ± 1.28 3.32 ± 1.27 10.65⁎ b.001 .001 .74 0.83 ± 0.82
EDE-Q R 3.02 ± 1.46 3.44 ± 1.77 2.72 ± 1.67 0.03 .41 .79 .02 0.83 ± 1.04
EDE-Q EC 2.03 ± 1.54 3.26 ± 1.50 2.97 ± 1.47 10.71⁎ b.001 .001 .75 0.40 ± 0.61
EDE-Q WC 2.53 ± 1.45 3.58 ± 1.34 3.56 ± 1.37 11.29⁎ b.001 b.001 1.00 0.95 ± 0.95
EDE-Q SC 3.26 ± 1.82 4.05 ± 1.41 4.07 ± 1.52 5.08⁎ .02 .009 1.00 1.12 ± 1.06
One-way ANOVA between AN-R, AN-B/P, and BN groups; post hoc paired contrasts with Bonferroni correction for the pairwise comparison among the groups.
A separate 1-way ANOVA between the healthy control and the diagnostic groups was performed (only descriptive statistics were shown) All post hoc
comparisons, with the exception of age, were significant at P b .001. HC indicates healthy controls; BMI, body mass index; GSI, Global Severity Index; EES TS,
EES total score; EES Ang/Frust, EES Anger/Frustration; EES Anx, EES Anxiety; EES Dep, EES Depression; FLC, fear of loss of control over eating (month
frequency); SBE, subjective binge eating (month frequency); OBE: objective binge eating (month frequency); EDE-Q TS, EDE Questionnaire total score; EDE-
Q R, EDE Questionnaire restraint; EDE-Q EC, EDE Questionnaire eating concern; EDE-Q WC, EDE Questionnaire weight concern; EDE-Q SC, EDE
Questionnaire shape concern.
⁎ P b .01.

Table 2
Pearson correlations of eating-related features
EES TS FLC OBE SBE EDE-Q TS EDE-Q R EDE-Q EC EDE-Q WC
AN-R FLC 0.37⁎
OBE 0.06 0.24
SBE 0.32 0.31 0.18
EDE-Q TS 0.31 0.55⁎ 0.45⁎ 0.27
EDE-Q R 0.39⁎ 0.56⁎ 0.37⁎ 0.15 0.50⁎
EDE-Q EC 0.14 0.52⁎ 0.38⁎ 0.13 0.87⁎ 0.40⁎
EDE-Q WC 0.24 0.41⁎ 0.40⁎ 0.25 0.88⁎ 0.27 0.65⁎
EDE-Q SC 0.32⁎ 0.45⁎ 0.35 0.30 0.94⁎ 0.35⁎ 0.74⁎ 0.90⁎
AN-B/P FLC 0.04
OBE 0.12 0.30
SBE 0.75⁎ 0.47⁎ 0.20
EDE-Q TS −0.01 0.68⁎ 0.21 0.12
EDE-Q R −0.04 0.53⁎ −0.03 −0.02 0.78⁎
EDE-Q EC −0.03 0.76⁎ 0.24 0.17 0.85⁎ 0.55⁎
EDE-Q WC 0.07 0.48⁎ 0.23 0.19 0.88⁎ 0.52⁎ 0.67⁎
EDE-Q SC 0.05 0.60⁎ 0.30 0.13 0.86⁎ 0.48⁎ 0.71⁎ 0.85⁎
BN FLC 0.26
OBE 0.69⁎ 0.30⁎
SBE 0.02 0.16 0.28
EDE-Q TS 0.33 0.67⁎ 0.39⁎ 0.18
EDE-Q R 0.12 0.45⁎ 0.18 0.06 0.75⁎
EDE-Q EC 0.47⁎ 0.79⁎ 0.45⁎ 0.19 0.87⁎ 0.53⁎
EDE-Q WC 0.30 0.52⁎ 0.30⁎ 0.15 0.90⁎ 0.50⁎ 0.78⁎
EDE-Q SC 0.33 0.50⁎ 0.37⁎ 0.19 0.87⁎ 0.46⁎ 0.70⁎ 0.83⁎
EES TS indicates EES total score; FLC, fear of loss of control overeating (week frequency); OBE, objective binge eating (week frequency); SBE, subjective
binge eating (week frequency); EDE-Q TS, EDE Questionnaire total score; EDE-Q R, EDE Questionnaire restraint; EDE-Q EC, EDE Questionnaire eating
concern; EDE-Q WC, EDE Questionnaire weight concern; EDE-Q SC, EDE Questionnaire shape concern.
⁎ P b .01, Pearson correlation.
 V. Ricca et al. / Comprehensive Psychiatry 53 (2012) 245–251
Fig. 1. Determinants of eating behaviors for diagnostic groups. Multiple
linear regression analyses. Statistics: multiple linear regression, *P b .05 and
**P b .01.
restraint for AN-R, subjective binge eating for AN-B/P,
and objective binge eating for BN. Age, sex, and other
variables, which showed a P b .01 correlation with the
dependent variable at Pearson correlation, were entered in
the models as covariates.
According to these analyses (Fig. 1), in patients with
AN-R, restraint was mainly associated with fear of loss of
control over eating and emotional eating, even if the latter
showed a weaker association. Furthermore, in the multi-
variate model, emotional eating was the main determinant
of subjective and objective binge eating for patients with
AN-B/P and BN, respectively, and fear of loss of control
over eating was not associated.
4. Discussion
In the present study, we evaluated the relationships
between emotional eating and ED specific and general
psychopathology in patients with AN-R, AN-B/P, and BN
and in healthy control subjects.
Two main findings can be drawn from the present study:
- Emotional eating is an important clinical dimension for
both AN and BN, and even patients with AN-R
showed higher emotional eating level compared with
healthy control subjects.
249
- Emotional eating is significantly associated with
specific eating attitudes and behavior, according to
the different diagnoses: restraint for patients with AN-
R, subjective binge eating for patients with AN-B/P,
and objective binge eating for patients with BN. Fear
of loss of control over eating plays a different role in
the 3 groups of patients.
As far as eating psychopathology is concerned, the 3 EDs
diagnostic groups showed significant differences, with
patients with BN and AN-B/P reporting higher EDE-Q
scores and higher sense of loss of control, compared with
patients with AN-R. These results might suggest a similar
pattern of eating psychopathology in patients with binge
eating [19,36], regardless of the DSM-IV distinction between
patients with AN and BN.
On the contrary, the 3 diagnostic groups showed similar
level of emotional eating, which was higher compared with
healthy controls, confirming the observation that patients
with ED reported higher levels of emotional eating compared
with the general population [37] and suggesting that
emotional eating is associated not just with the presence of
binge eating, but it is a common dimension in all EDs, even
in patients with AN-R [18].
Therefore, our findings seem to challenge the definition
of emotional eating as “eating in response to a range of
negative emotions” and suggest that it should be considered a
cognitive construct better defined as a “desire to eat in
response to a range of different emotions” according to the
Emotional Eating Questionnaire [6]. The presence of high
emotional eating levels in all ED groups taken into account is
coherent with the models that conceptualizes EDs as
disorders of affect regulation, considering the impairment
in the cognitive capacity to process and regulate emotions as
the primary regulatory disturbance [38]. According to this
model, ED behaviors, such as binge eating and compensa-
tory behaviors, as well as restricted food consumption, are
interpreted as responses to cope with intense or relatively
undifferentiated emotional states [18,39,40].
We also found a different pattern of relationship between
emotional eating and loss of control over eating, according to
the different diagnostic groups. Emotional eating was
associated with subjective and objective binge eating in
patients with AN-B/P and BN, respectively, confirming the
importance of emotional eating in the maintenance of binge
eating symptom [9,15,39].
Furthermore, emotional eating was associated not only
with eating a large amount of food [6,8,9] but also with
subjective binge eating, suggesting that the desire to eat, to
cope with negative feelings, is not associated only with the
experience of overeating, but also with the subjective
experience of loss of control.
As far as specific emotions are concerned, patients with
AN-B/P and BN showed higher depression emotional eating
compared with patients with AN-R, without any significant
difference between them, whereas the 3 groups showed
250 V. Ricca et al. / Comprehensive Psychiatry 53 (2012) 245–251
similar level of anxiety emotional eating. This distinction
among specific emotions related with emotional eating is in
contrast with the findings of Waller and Osman [41], who
observed that the link between emotional eating and bulimia
is a relatively general one, rather than being a specific effect
of eating in response to anger, anxiety, or depression.
Among patients with AN-R, emotional eating was
significantly associated with eating restraint. These data are
in contrast with the findings of Waller and Osman [41], who
reported that emotional eating of anorexic patients was
linked with bulimia and higher weight, but not with
restrictive attitudes, and could be explained by the model
of Heatherton and Baumeister [42], according to which,
extreme food restriction, as well as binge eating function, in
part, helps individuals to escape from aversive self-
awareness, which includes negative self-perceptions and
emotional distress.
The relationship between emotional eating and different
eating behaviors in patients with AN-R, AN-B/P, and BN
should be interpreted taking in consideration the role of fear
of loss of control over eating, which was associated with
emotional eating in all the 3 groups, and it was positively
correlated with restraint in patients with AN-R and with
subjective and objective binge eating in patients with AN-B/
P and BN, respectively. These interactions were analyzed by
means of multivariate models. According to these analyses, a
positive relationship between emotional eating and binge
eating (subjective and objective) was observed in patients
with AN-B/P and BN, even when controlling for fear of loss
of control. Among patients with AN-R, emotional eating was
associated with restraint, but this association was lost when
controlling for fear of loss of control over eating, which was
the principal determinant of restraint.
Like emotional eating, also fear of loss of control over
eating appeared to be a common dimension to all the EDs
diagnoses considered, confirming previous observations
[43-45]. For individuals with ED, the construct of control
can be conceptualized as anxious perception of low control
over external threats and emotional reactions, according to
the pattern of association between emotional eating and
fear of loss of control over eating we observed. Feeling
control over a threat involves predicting the threat and also
being able to respond to the threat in a way that reduces it
and enhances the sense of personal competence and self-
efficacy [46-50]. Thus, to regain a feeling of control,
individuals with ED commonly focus on eating and body
size. In this sense, it is possible that eating restraint
enhances the subjective perception of being in control [51],
explaining the specific pattern of association we found in
patients with AN-R.
Due to the cross-sectional nature of our study, we cannot
detect the possible role of emotional eating as a risk factor for
the development of binge eating and BN among patients with
AN-R. Stice et al [52] found that emotional eating was an
important predictor for the onset of binge eating in
adolescent girls, and Van Strien [53-55] observed that
emotional eating distinguishes dieters with high vs low
susceptibility toward failure of dietary restraint. A longitu-
dinal investigation is needed to confirm these findings.
Finally, from a clinical point of view, our results suggest
that treatment in both patients with AN subtypes and BN
should also focus specifically on the awareness and
regulation of emotional eating [18], which is significantly
associated with abnormal eating attitudes and behavior, and
on the awareness and reduction of the fear of loss of control
over eating, which seems to be a relevant dimension for all
patients with ED.
This study has some limitations:
- Being cross-sectional in nature, it does not allow for
the detection of any causal relationship between the
variables taken into account.
- Different important data of this study were self-
reported, thus possibly determining potential subjec-
tive bias. Errors or memory biases could have affected
the retrospectively collected data (eg, the frequency of
binge eating episodes).
- Temperament and personality disorders were not
assessed. This issue represents a potential limitation,
considering their possible mediating role for different
clinical variables considered in our study.
- Our findings refer to patients seeking treatment and
cannot be generalized to the whole population with
these syndromes.
References
[1] Greeno GG, Wing RR. Stress-induced eating. Psychol Bull
1994;115:444-64.
[2] Macht M. How emotions affect eating: a five-way model. Appetite
2008;50(1):1-11.
[3] Schachter S, Goldman R, Gordon A. Effects of fear, food deprivation,
and obesity on eating. J Pers Soc Psychol 1968;10:91-7.
[4] Herman CP, Polivy J. A boundary model for the regulation of eating.
Res Publ Assoc Res Nerv Ment Dis 1984;62:141-56.
[5] Heatherton TF, Herman CP, Polivy J. Effects of physical threat and ego
threat on eating behavior. J Pers Soc Psychol 1991;60:138-43.
[6] Arnow B, Kenardy J, Agras WS. The Emotional Eating Scale: the
development of a measure to assess coping with negative affect by
eating. Int J Eat Disord 1995;18:79-90.
[7] Engelberg MJ, Steiger H, Gauvin L, Wonderlich SA. Binge
antecedents in bulimic syndromes: an examination of dissociation
and negative affect. Int J Eat Disord 2007;40(6):531-6.
[8] Pinaquy S, Chabrol H, Simon C, Louvet JP, Barbe P. Emotional eating,
alexithymia, and binge-eating disorder in obese women. Obesity
2003;11(2):195-201.
[9] Masheb RM, Grilo CM. Emotional overeating and its associations with
eating disorder psychopathology among overweight patients with
binge eating disorder. Int J Eat Disord 2006;39:141-6.
[10] Stein RI, Kenardy J, Wiseman CV, Dounchism JZ, Arnow BA, Wilfley
DE. What's driving the binge in binge eating disorder? A prospective
examination of precursors and consequences. Int J Eat Disord 2007;
40(3):195-203.
[11] Dingemans AE, Martijn C, Jansen AT, van Furth EF. The effect of
suppressing negative emotions on eating behaviour in binge eating
disorder. Appetite 2009;52:51-7.
 V. Ricca et al. / Comprehensive Psychiatry 53 (2012) 245–251
[12] Ricca V, Castellini G, Lo Sauro C, Ravaldi C, Lapi F, Mannucci E,
et al. Correlations between binge eating and emotional eating in a
sample of overweight subjects. Appetite 2009;53(3):418-21.
[13] Zeeck A, Stelzer N, Linster HW, Joos A, Hartmann A. Emotion and
eating in binge eating disorder and obesity. Eur Eat Disord Rev 2010,
doi:10.1002/erv.1099.
[14] Wiser S, Telch CF. Dialectical behavior therapy for binge-eating
disorder. J Clin Psychol 1999;55:755-68.
[15] Deaver CM, Miltenberger RG, Smyth J, Meidinger A, Crosby R. An
evaluation of affect and binge eating. Behav Modif 2003;27:578-99.
[16] Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet
2010;375(9714):583-93.
[17] Zaitsoff SL, Grilo CM. Eating disorder psychopathology as a marker of
psychosocial distress and suicide risk in female and male adolescent
psychiatric inpatients. Compr Psychiatry 2010;51(2):142-50.
[18] Torres S, Guerra MP, Lencastre L, Roma-Torres A, Brandão I, Queirós
C, et al. Cognitive processing of emotions in anorexia nervosa. Eur Eat
Disord Rev 2010 [Epub ahead of print].
[19] Vervaet M, van Heeringen C, Audenaert K. Personality-related
characteristics in restricting versus binging and purging eating
disordered patients. Compr Psychiatry 2004;45(1):37-43.
[20] Steiger H, Seguin JR. Eating disorders: anorexia and bulimia nervosa.
In: Millon T, & Blaney PH, editors. Oxford textbook of psychopa-
thology. Toronto, Canada: Oxford University Press; 1999. p. 365-89.
[21] Peat C, Mitchell JE, Hoek HW, Wonderlich SA. Validity and utility of
subtyping anorexia nervosa. Int J Eat Disord 2009;42(7):590-4.
[22] Burd C, Mitchell JE, Crosby RD, Engel SG, Wonderlich SA, Lystad
C, et al. An assessment of daily food intake in participants with
anorexia nervosa in the natural environment. Int J Eat Disord
2009;42(4):371-4.
[23] Kissileff HR, Zimmerli EJ, Torres MI, Devlin MJ, Walsh BT. Effect of
eating rate on binge size in bulimia nervosa. Physiol Behav 2008;
93(3):481-5.
[24] Wolfe BE, Baker CW, Smith AT, Kelly-Weeder S. Validity and utility
of the current definition of binge eating. Int J Eat Disord 2009;
42(8):674-86.
[25] Samuels F, Zimmerli EJ, Devlin MJ, Kissileff HR, Walsh BT. The
development of hunger and fullness during a laboratory meal in
patients with binge eating disorder. Int J Eat Disord 2009;42(2):125-9.
[26] Kiezebrink K, Campbell D, Mann E, Blundell J. Similarities and
differences between excessive exercising anorexia nervosa patients
compared with DSM-IV defined anorexia nervosa subtypes. Eat
Weight Disord 2009;14(4):199-204.
[27] First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical
Interview for DSM-IV Axis I Disorders. Patient edition (SCID-P,
Version 2). New York: New York State Psychiatric Institute,
Biometrics Research; 1995.
[28] Fairburn CG, Cooper Z. The Eating Disorder Examination. In: Wilson
GT, & Fairburn CG, editors. Binge eating: nature, assessment, and
treatment, 12th edNew York (N.Y.): Guilford Press; 1993. p. 317-60.
[29] Bardone-Cone AM, Joiner Jr TE, Crosby RD, Crow SJ, Klein MH, le
Grange D, et al. Examining a psychosocial interactive model of binge
eating and vomiting in women with bulimia nervosa and subthreshold
bulimia nervosa. Behav Res Ther 2008;46(7):887-94.
[30] American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders (4th revised). Washington, DC: American
Psychiatric Association; 2000.
[31] Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or
self-report questionnaire? Int J Eat Disord 1994;16:363-70.
[32] Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJ. Validity of the
Eating Disorder Examination Questionnaire (EDE-Q) in screening for
eating disorders in community samples. Behav Res Ther 2004;42:551-67.
251
[33] Beck AT, Steer R. Manual for revised Beck Depression Inventory.
New York: Psychological Corporation; 1987.
[34] Spielberger CD, Gorsuch RL, Lushene RE. Manual for the State-Trait
Anxiety Inventory. Palo Alto (Calif): Consulting Psychologists Press;
1970.
[35] Derogatis LR, Lipman RS, Covi L. SCL-90: an outpatient psychiatric
rating scale-preliminary report. Psychopharmacol Bull 1973;9:13-28.
[36] Williamson DA. Does the evidence point to a binge eating phenotype?
Comment on Gordon et al. (2007) and Wonderlich et al. (2007). Int J
Eat Disord 2007;40(Suppl):S72-5.
[37] Spoor ST, Bekker MH, Van Strien T, van Heck GL. Relations between
negative affect, coping, and emotional eating. Appetite 2007;48(3):
368-76.
[38] Taylor CB, Altman T. Priorities in prevention research for eating
disorders. Psychopharmacol Bull 1997;33(3):413-7.
[39] Meyer C, Waller G, Waters A. Emotional states and bulimic
psychopathology. In: Hoek HW, Treasure JL, & Katzman MA,
editors. Neurobiology in the treatment of eating disorders. Chicester,
UK: Wiley; 1998. p. 271-89.
[40] Corstorphine E, Mountford V, Tomlinson S, Waller G, Meyer C.
Distress tolerance in the eating disorders. Eating behaviors 2007;
8(1):91-7.
[41] Waller G, Osman S. Emotional eating and eating psychopathology
among non–eating-disordered women. Int J Eat Disord 1998;23:
419-24.
[42] Heatherton TF, Baumeister RF. Binge eating as escape from self-
awareness. Psychol Bull 1991;110:86-108.
[43] Bruch H. Eating disorders: obesity, anorexia nervosa, and the person
within. New York: Basic Books; 1973.
[44] Button E. Eating disorders: a quest for control? In: & Button E, editor.
Personal construct theory and mental health. London, Sidney: Croom
Helm; 1985. p. 153-68.
[45] Fairburn CG, Harrison PJ. Eating disorders. Lancet 2003;361:407-16.
[46] Mineka S, Zinbarg R. Conditioning and etiological models of anxiety
disorders: stress in dynamic-context anxiety models. In: & Hope DA,
editor. Nebraska symposium on motivation: Vol. 43. Perspectives on
anxiety, panic, and fear. Lincoln: University of Nebraska Press; 1996.
p. 135-210.
[47] Rapee RM, Craske MG, Brown TA, Barlow DH. Measurement of
perceived control over anxiety-related events. Behav Ther 1996;27:
279-93.
[48] Shapiro Jr DH, Astin A. Control therapy, an integrated approach to
psychotherapy, health and healing. New York: John Wiley & Sons;
1998.
[49] Hoyer J, Becker ES, Roth WT. Characteristics of worry in GAD
patients, social phobics, and controls. Depress Anxiety 2001;13(2):
89-96.
[50] Barlow DH. Anxiety and its disorders: the nature and treatment of
anxiety and panic. 2nd ed. New York: Guilford; 2002.
[51] Slade P. Towards a functional analysis of anorexia nervosa and bulimia
nervosa. Br J Clin Psychol 1982;21(Pt 3):167-79.
[52] Stice E, Presnell K, Spangler D. Risk factors for binge eating onset in
adolescent girls: a 2-year prospective investigation. Health Psychol
2002;21:131-8.
[53] Van Strien T. Are most dieters unsuccessful? An alternative
interpretation of the confound of success and failure in the
measurement of restraint. Eur J Psychol Assess 1997;13:186-94.
[54] Van Strien T. The concurrent validity of a classification of dieters with
low versus high susceptibility toward failure of restraint. Addict Behav
1997;22:587-97.
[55] Van Strien T. Success and failure in the measurement of restraint: notes
and data. Int J Eat Disord 1999;28:460-4.