Objective and Subjective Binge Eating in UnderweightEating Disorders: Associated Features and Treatment

Outcome

Riccardo Dalle Grave, MD1

Simona Calugi, PhD1

Giulio Marchesini, MD2*

ABSTRACT

Objective: To define the utility of the

DSM-IV-TR definition of binge eating, as

it applies to anorexia nervosa (AN) and

underweight eating disorder not other-

wise specified (ED-NOS).

Method: We investigated the psychopa-

thological features associated with

bulimic episodes in 105 underweight

individuals with eating disorders who

reported regular objective bulimic epi-

sodes with or without subjective bulimic

episodes (OBE group, n 5 33), regular

subjective bulimic episodes only (SBE

group, n 5 36) and neither objective nor

subjective bulimic episodes (n 5 36, no-

RBE group). The Eating Disorder Exami-

nation (EDE), anxiety, depression, and

personality tests were administered

before and upon completion of inpatient

cognitive behavior therapy (CBT) treat-

ment 6 months later.

Results: Compared with the SBE group,

OBE subjects had higher body mass

index, and more frequent self-induced

vomiting, while both OBE and SBE groups

had more severe eating disorder psycho-

pathology and lower self-directness than

the no-RBE group. Dropout rates and

outcomes in response to inpatient CBT

were similar in the three groups.

Discussion: Despite a few significant dif-

ferences at baseline, the similar outcome

in response to CBT indicates that categoriz-

ing patients with underweight eating disor-

der on the basis of the type or frequency of

bulimic episodes is of limited clinical utility.VVC 2011 by Wiley Periodicals, Inc.

Keywords: eating disorders; personality;

binge eating; cognitive-behavioral therapy

(Int J Eat Disord 2012; 45:370–376)

Introduction

Binge eating is a cardinal criterion for the diagnosisof bulimia nervosa (BN) and the provisional diag-nosis of binge eating disorder (BED),1 but it is alsoreported by individuals with anorexia nervosa (AN)of the binge-eating/purging type (AN-BP).1

According to the DSM-IV-TR, an episode of bingeeating is characterized both by eating an amount offood that would normally be regarded as too large,and by a sense of lack of control over eating.1

Unfortunately, there are no specific guidelinesregarding the threshold of the amount of food nec-essary to satisfy the inclusion in the AN-BP type.

This causes difficulties in classifying AN-BP, espe-cially when clinicians see underweight patientswho report regular episodes of loss of control overeating but do not have regular episodes of purging.In addition, individuals with eating disorders mayfail to identify the binge episodes on the basis offood amount, giving greater emphasis to the loss ofcontrol than to the amount of food in their defini-tion of binge eating.2,3

The evidence supporting the validity of the DSM-IV-TR definition of binge eating as this applies toBN and variants of BN is limited.4–6 In patients withBN, ‘‘objective’’ and ‘‘subjective’’ bulimic episodes,as defined according to the Eating Disorder Exami-nation (EDE),7 seem to be associated with a similarseverity of clinical impairment and/or other clinicaldata (e.g., psychopathology, past-history of AN,psychiatric symptoms, interpersonal distress, lowself-esteem and self-efficacy, and social adjust-ment).8 Other clinical studies confirmed that objec-tive and subjective bulimic episodes are associatedwith similar levels of depression or anxiety,9,10 andthat the age of onset and the predictors of the twotypes of bulimic episodes are almost identical,11

while their frequency is different.12 Findings from

Accepted 17 April 2011

1 Department of Eating Disorder and Obesity, Villa Garda

Hospital. Garda (Vr), Italy2 Unit of Metabolic Diseases & Clinical Dietetics, ‘‘Alma Mater

Studiorum,’’ University of Bologna, Policlinico S. Orsola, Bologna,

Italy

*Correspondence to: Giulio Marchesini, Unit of Metabolic

Diseases, ‘‘Alma Mater Studiorum’’ University of Bologna,

Policlinico S. Orsola, 9, Via Massarenti, Bologna I-40138, Italy.

E-mail: giulio.marchesini@unibo.it

Published online 7 June 2011 in Wiley Online Library

(wileyonlinelibrary.com). DOI: 10.1002/eat.20943

VVC 2011 Wiley Periodicals, Inc.

370 International Journal of Eating Disorders 45:3 370–376 2012

REGULAR ARTICLE (CE ACTIVITY)

community-based studies similarly suggest thatindividuals with bulimic-type eating disorders whoreport objective bulimic episodes are similar, interms of eating disorder and comorbid psychopa-thology, to those who report subjective bulimic epi-sodes.13–15

The possible effects of the type and frequency ofbulimic episode on treatment response have rarelybeen considered. The limited data available havesuggested that subjective episodes remit moreslowly in patients with BED16 and both persist atthe end of treatment in patients with BN.17 Subjec-tive episodes did not respond well to self-monitor-ing in women with either BN or BED,18 whereasthis strategy was effective in reducing objective epi-sodes.19 As to the influence on treatment outcome,only the presence of subjective episodes predictedthe response to placebo in participants with BED.20

As pointed out in a recent review,6 no meaningfulinformation has ever been reported on the bingeeating episodes in underweight ED-NOS and AN.Limited information is also available on the per-sonality characteristics of the underweight individ-uals with different types of bulimic episodes andon their role on treatment response, a key aspect todefine the clinical utility of a DSM diagnosis.21 Thegoal of this study was, therefore, to investigate thepsychopathological features associated with objec-tive and subjective bulimic episodes in under-weight individuals with eating disorder, and to testtheir role on treatment outcome.

Method

Participants

The sample consisted of consecutive female subjects

admitted to the eating disorder inpatient unit of Villa

Garda Hospital (Northern Italy) between November 2003

and November 2006. The subjects were referred to our

institution from all over Italy by general practitioners or

by eating disorder specialists.

Subjects were included if they met the following crite-

ria: (a) age, 12–65 years; (b) body mass index (BMI) �17.5

kg/m2; (c) diagnosis of an eating disorder of clinical se-

verity assessed by EDE; (d) failure of less intensive outpa-

tient treatment or an eating disorder of clinical severity

not manageable in an outpatient setting. According to

our protocol, subjects with active substance abuse and

acute psychotic disorders are not considered for hospital

admission and the first author (RDG) evaluated the pres-

ence of these two comorbid conditions during an eligibil-

ity interview before admission.

The research was reviewed and approved by the Insti-

tutional Review Board of Villa Garda Hospital, Verona,

and all participants (or their legal guardians for the 17

patients under 18) gave written informed consent to the

anonymous use of personal data.

Inpatient Treatment Protocol

The treatment has been described in detail else-

where.22,23 The program is derived from the cognitive

behavior treatment of eating disorders (CBT-E),24 but has

been adapted for an inpatient setting. The treatment is

manual-based,22 lasts 20 weeks and comprises 13 weeks

of inpatient therapy followed by 7 weeks of day-hospital

admission, with the patient living close to the hospital

and spending the weekends at home.

Assessment and Measures

All data were collected on the first day of admission

and on the last day of day-hospital treatment. Demo-

graphic and clinical variables were assessed during inter-

view. Weight (to the nearest 0.1 kg) was measured by a

calibrated scale and height (to the nearest 0.5 cm) by a

stadiometer. Patients were measured with underwear

and without shoes.

A validated Italian translation of EDE (EDE12.0D),7,25

completed by a senior specialist in the field (RDG), was

used to generate the operational definition of eating dis-

order diagnosis according to DSM-IV and to evaluate the

eating disorder psychopathology, including bulimic epi-

sodes. The EDE inter-rater reliability has been estimated

to be 0.97–0.99.26 The EDE section about ‘‘bulimic epi-

sodes and other episodes of overeating’’ produces an

accurate measure of objective and subjective bulimic

episodes, as it is an investigator-based interview where

bulimic episodes are classified as objective or subjective

according to specific guidelines after obtaining a detailed

report of the amount of food consumed during each epi-

sode.8 For the purpose of this study, bulimic episodes

were defined ‘‘regular’’ if they occurred at least once a

week in the previous 4 weeks, and ‘‘nonregular’’ if they

were recorded less than once a week.27,28

As detailed below, the number of participants report-

ing in the EDE interview regular objective bulimic epi-

sodes but not regular subjective bulimic episodes was

small. We therefore conducted a preliminary analysis in

which the characteristics of participants who reported

only objective bulimic episodes (n 5 14) were compared

with those of participants who reported both objective

and subjective bulimic episodes (n 5 19). Results of this

analysis failed to reveal any difference in the clinical

characteristics in relation to the co-presence of subjec-

tive bulimic episodes, with the exception of the eating

concern scale of EDE, higher in subjects with subjective

episodes (4.6 6 1.1 vs. 3.6 6 1.1; p 5 .012). We therefore

OBJECTIVE AND SUBJECTIVE BINGE EATING IN EDS

International Journal of Eating Disorders 45:3 370–376 2012 371

took the decision to group participants who reported

objective but not subjective bulimic episodes with those

who reported both objective and subjective bulimic epi-

sodes (OBE group). Then, we compared the OBE group

with the participants who reported regular subjective

(but not objective) bulimic episodes (SBE group) and

with those who reported neither objective nor subjective

bulimic episodes (no-RBE group).

The Temperament and Character Inventory (TCI)29

was used to assess personality characteristics, based on a

psychobiologic model of personality. This model includes

four temperament dimensions (novelty seeking, harm

avoidance, reward dependence, and persistence) and

three character dimensions (self-directedness, coopera-

tiveness, and self- transcendence). The TCI has good in-

ternal consistency,29,30 inter-rater and test–retest reliabil-

ity,29 and it is validated in its Italian version.31

The Beck Depression Inventory (BDI)32 and the State-

Trait Anxiety Inventory (STAI Form Y-1)33 were used to

assess the presence and severity of depression and trait

levels of anxiety, respectively. Both inventories have

excellent internal reliability, good test–retest reliability,

good criterion validity32,34 and have been validated in

their Italian versions.35,36

Statistical Analyses

Statistical analyses were carried out by means of SPSS

Version 15.0 (SPSS, Chicago). Continuous variables were

categorized as mean 6 SD or as median [interquartile

range, IQR] and categorical variables as frequency and

percentage. The differences in demographic and clinical

variables between the groups were tested for significance

by means of ANOVA, Kruskal Wallis test, or v2 test, as

appropriate. Repeated-measures analysis of variance for

continuous variables or McNemar test for categorical

variables was used to analyze changes in clinical varia-

bles between groups. Spearman’s correlation was used to

analyze the association between the number of objective

and subjective bulimic episodes and other eating disor-

der behaviors and psychopathology scores.

Finally, we tested the independent association

between the frequency of both types of bulimic episodes

at baseline (independent variables) and the changes in

EDE global score or BMI (dependent variables) following

treatment in two different linear regression models. Both

models were adjusted for initial BMI, age, frequency of

self-induced vomiting, laxative and diuretic misuse, and

intense exercising to control shape or weight, considered

potential predictors of outcome. Change in BMI was

added as additional dependent variable in the EDE

model. BMI and EDE scores were used as outcome varia-

bles in the regression analysis as weight gain is the pri-

mary goal for AN patients,37 and improved EDE-meas-

ured eating disorder psychopathology is the main target

of inpatient cognitive behavioral intervention.

Results

Participants

The participants were 105 underweight eatingdisorder patients (mean age, 26.0 6 9.0 years;mean BMI, 14.6 6 1.6 kg/m2); 66 (62.9%) were clas-sified as AN, and 39 as ED-NOS. According to thedefinitions described in the Methods section, 33participants were classified in the OBE group, 36 inthe SBE group, and 36 in the no-RBE group. In theOBE group, 19 (57.6%) had a diagnosis of AN, and14 were ED-NOS, while in the SBE group, 27 (75%)were AN and 9 ED-NOS, and in the no-RBE group,20 (55.6%) were AN and 16 were ED-NOS (v2 53.49, p 5 .175)

Clinical Characteristics of Participants at

Baseline by Subgroup

Individuals with regular bulimic episodes, andparticularly those with both types of episodes, werecharacterized by significantly higher BMI, a highernumber of episodes of self-induced vomiting andhigher EDE eating concern subscale and globalscores, as well as lower scores on the self-directed-ness scale of TCI. There were no baseline differen-ces between groups on any of the remaining studyvariables (Table 1).

Associations between OBE and SBE Frequency

and Eating Disorder Features

The number of OBEs was positively associatedwith the number of episodes of self-induced vomit-ing and of laxative misuse and with the EDE eatingconcern subscale, and negatively with the episodesof intense exercising. The number of subjective epi-sodes was positively associated with the number ofepisodes of self-induced vomiting, the eating,weight, and shape concern subscales of EDE andwith the EDE global score (Table 2).

Treatment Outcome of OBE, SBE, and No-RBE

Groups

73 patients (69.5%) completed the treatment pro-gram (continuers), whereas 32 (30.5%) left the pro-gram before concluding the planned 20 weeks(dropouts). They had a similar BMI at baseline(14.7 6 1.7 kg/m2 in completers and 14.2 6 1.6 indropouts; t 5 1.66, p 5 .099). The dropout rate wassimilar in relation to bulimic episodes (OBE: 11/33,33.3%; SBE: 12/36, 33.3%; no-RBE: 9/36, 25.0%; v2

5 0.77, p 5 .679) and also the time to dropout didnot differ (median, 22 days [IQR, 42] vs. 49 [14] vs.35 [64], respectively; v2 5 3.10, p 5 .212). The me-dian number of objective and subjective bulimicepisodes in the last 28 days before admission was

DALLE GRAVE ET AL.

372 International Journal of Eating Disorders 45:3 370–376 2012

not different between drop-outs and completers(Objective episodes: 2 [IQR, 84] and 0.5 [30] z 520.17, p 5 .861; Subjective episodes: 10 [53] and18.5 [52] z5 20.96, p5 .338, respectively).

Pre- and post-treatment scores on measures

of eating disorder and comorbid psychopathol-

ogy for each group are shown in Table 3. BMI

as well as all psychological and behavioral

measures improved the persistence and self-

transcendence subscales of TCI decreased,

whereas the scores of harm avoidance and self-

directedness increased.

All groups achieved a mean normal BMI withtreatment, but the no-RBE group regained signifi-cantly more weight. In contrast, the eating concernsubscale of EDE was more significantly improvedin the OBE group. Finally, the number of bulimicepisodes, of episodes of self-induced vomiting, lax-ative misuse and intense exercising was reduced inall groups, whereas they were frequently reportedat baseline.

Factors Associated with Treatment Outcome

In a linear regression model, changes in eating dis-order psychopathology (EDE global score) were neg-atively associated with the number of SBEs at base-

TABLE 1. Descriptive statistics for age, body weight and measures of eating disorder and comorbid psychopathologyin patients with regular objective with/without subjective bulimic episodes (OBE group), with regular subjective with-out subjective bulimic episodes (SBE group) and without regular bulimic episodes (no-RBE group)

OBE Group (N5 33) SBE Group (N5 36) No-RBE Group (N5 36) Teste p Value

Present BMI (kg/m2) 15.4 (1.6) 14.0 (1.3)a 14.4 (1.7)a 8.14 0.001Maximum BMI (kg/m2) 22.4 (3.7) 20.7 (4.0) 19.5 (2.5)a 6.09 0.003Minimum BMI (kg/m2) 13.9 (1.7) 13.1 (1.5) 13.4 (1.7) 2.31 0.105Pre-morbid BMI (kg/m2) 21.3 (3.9) 20.2 (3.8) 19.0 (2.0)a 3.96 0.022Menarche (years) 13.0 (2.4) 12.4 (1.7) 12.7 (1.7) 0.67 0.513Age (years) 27.9 (6.9) 25.8 (10.5) 24.3 (9.0) 1.52 0.225Age at onset (years) 16.6 (3.8) 16.0 (6.7) 17.9 (5.7) 0.95 0.391ED duration (months)b 129 [138] 66 [168] 30 [425]a 8.27 0.016Suicidal attemptsc 7 (21.2%) 8 (22.9%) 4 (11.1%) 1.92 0.383Eating Disorder Examinationd

Objective bulimic episodesc 33 (100%) 0 0 - -Subjective bulimic episodesc 19 (57.6%) 36 (100%) 0 - \0.001Self-induced vomiting episodec 27 (81.8%) 8 (22.2%) 3 (8.3%)a,f 44.89 \0.001Laxative misuse episodesc 10 (30.3%) 5 (13.9%) 4 (11.1%) 4.68 0.085Diuretics misuse episodesc 3 (9.1%) 3 (8.3%) 1 (2.8%) 1.35 0.510Intense exercising episodesc 12 (36.4%) 21 (58.3%) 20 (55.6%) 3.89 0.143Restraint 3.5 (1.7) 3.9 (1.5) 3.5 (1.7) 0.63 0.532Eating concern 4.1 (1.2) 3.4 (1.4) 2.5 (1.3)a,f 12.71 \0.001Weight concern 3.6 (1.5) 3.8 (1.6) 2.9 (1.7) 3.07 0.051Shape concern 3.7 (1.0) 3.9 (1.2) 3.1 (1.3)f 4.53 0.013

Global score 3.7 (1.0) 3.7 (1.2) 3.0 (1.3)a,f 4.60 0.012State-Trait Anxiety Inventory (Form Y) 59.3 (11.1) 60.5 (12.5) 55.7 (16.8) 1.14 0.325Beck Depression Inventory 30.8 (15.7) 31.8 (12.5) 27.2 (13.1) 1.07 0.346Temperament and Character InventoryNovelty Seeking 19.3 (6.7) 16.1 (4.6) 17.1 (5.4) 2.85 0.063Harm avoidance 21.4 (6.4) 23.0 (5.7) 22.3 (7.1) 0.50 0.611Reward dependence 14.6 (4.3) 14.9 (3.7) 15.3 (3.0) 0.322 0.725Persistence 4.9 (1.6) 5.3 (1.8) 5.7 (1.8) 1.95 0.147Self-directedness 19.0 (8.5) 18.4 (6.7) 24.4 (8.0)a,f 6.33 0.003Cooperativeness 30.8 (6.1) 28.4 (7.0) 31.9 (5.4) 2.93 0.058Self-transcendence 13.6 (7.2) 12.9 (5.6) 13.9 (5.3) 0.24 0.787

a p\ .05 vs. OBE group. Data are presented as mean (SD), asbmedian [interquartile range] or asc number of cases (%).d In the last 28 days before examination.e ANOVA, Kruskal Wallis, v2 or Fisher’s exact test as necessary.f p\ .05 vs. SBE group

TABLE 2. Spearman’s correlation coefficients (rho val-ues) between the frequency of objective and subjectivebulimic episodes, and frequency of extreme weight-con-trol behaviors and scores on subscales of the Eating Dis-order Examination

Eating Disorder ExaminationNo. of ObjectiveBulimic Episodes

No. of SubjectiveBulimic Episodes

No. of self-inducedvomiting episodes

0.669a 0.299a

No. of laxative misuse episodes 0.227b 0.136No. of diuretic misuse episodes 0.064 0.173No. of intense

exercising episodes20.253a 0.094

Restraint score 20.036 0.039Eating concern score 0.405a 0.403a

Weight concern score 0.026 0.234a

Shape concern score 0.012 0.293a

Global score 0.089 0.287a

a p\ .01b p\ .05.

OBJECTIVE AND SUBJECTIVE BINGE EATING IN EDS

International Journal of Eating Disorders 45:3 370–376 2012 373

line (b 5 20.24, t 5 22.02, p 5 .048) and with thenumber of intense exercising episodes (b 5 20.37, t5 23.35, p 5 .001), accounting for 31% of the var-iance of dependent variable. Age, baseline BMI,change in BMI, the number of objective bulimic epi-sodes, self-induced vomiting episodes, and laxativemisuse episodes were not independently significant.

The changes in BMI were negatively associatedwith baseline BMI (b 5 20.49, t 5 24.72, p\ .001),again accounting for 31% of the variance.

Discussion

In an inpatient CBT unit for eating disorder, weidentified three groups of underweight patientswho reported regular objective bulimic episodeswith or without subjective bulimic episodes (OBEgroup), regular subjective bulimic episodes only(SBE group) and neither objective nor subjectivebulimic episodes (no-RBE group). These groupswere assessed on a wide range of outcomes beforeand after treatment, including, age, age of men-

arche, BMI, premorbid BMI, eating disorder dura-tion, suicidal attempts, eating disorder psychopa-thology, general psychopathology, personality char-acteristics, and treatment outcome. The mainfindings were twofold. First, in terms of eating dis-order and comorbid psychopathology at baseline,similarities between the OBE and SBE groups out-weighed the differences, whereas differencesbetween these groups and the no-RBE group weremore pronounced. Second, all three groups hadsimilar outcomes in response to inpatient CBT.

At baseline, our underweight OBE, SBE, and no-RBE groups had similar sociodemographic andclinical characteristics and severity of general psy-chopathology, also including similar suicidalattempts, thus confirming previous studies in non-underweight clinical8–11 and community sampleswith objective and subjective bulimic epi-sodes.5,13,14 The OBE group had significantly higherBMI than the SBE and no-RBE groups, a findingreported previously in relation to individuals withbulimic-type eating disorders,5,15 and a highernumber of episodes of self-induced vomiting, a dif-

TABLE 3. Scores pre- and post-treatment on measures of eating disorder and comorbid psychopathology in patientswith objective bulimic episodes (OBE group), with subjective without subjective bulimic episodes, in subjects with regu-lar subjective bulimic episodes (SBE group) and in those without regular bulimic episodes (no-RBE group) who com-pleted the program

OBE Group (N5 22) SBE Group (N5 24) No OBE Group (N5 27)ANOVA for Repeated

Measures F (df5 1,2,68)

Pretreatment Posttreatment Pretreatment Posttreatment Pretreatment Posttreatment Time GroupTime3Group

Body mass index (kg/m2) 15.9 (1.2) 19.6 (0.8) 14.1 (1.2) 18.9 (1.5) 14.5 (1.9) 19.7 (1.0) 546.4* 8.30* 5.30§

Eating Disorder ExaminationObjective bulimic episodesa 22 (100%) 2 (9.1%)* 0 0 0 0 — — —Subjective bulimic episodesa 14 (63.6%) 9 (40.9%)£ 24 (100%) 3 (12.5%)* 0 5 (18.5%) — — —Self-induced vomitinga 16 (72.7%) 1 (4.5%)* 4 (16.7%) 0 2 (7.4%) 0 — — —Laxative misusea 6 (27.3%) 0§ 4 (16.7%) 0 4 (14.8%) 0 — — —Diuretics misusea 2 (9.1%) 0 2 (8.3%) 0 1 (3.7%) 0 — — —Intense exercisea 10 (45.5%) 1 (4.5%)§ 15 (62.5%) 4 (16.7%)* 14 (51.9%) 6 (22.2%)§ — — —Restraint 3.5 (1.8) 0.8 (0.7) 3.7 (1.4) 0.5 (0.6) 3.3 (1.7) 0.6 (0.9) 211.2* 0.25 0.53Eating concern 4.2 (1.4) 1.3 (1.0) 3.3 (1.2) 1.1 (0.9) 2.4 (1.2) 1.2 (1.2) 137.8* 5.75§ 7.81*Weight concern 3.6 (1.8) 2.4 (1.2) 3.6 (1.7) 1.6 (1.1) 2.9 (1.8) 1.8 (1.6) 44.2* 1.67 1.16Shape concern 3.7 (1.1) 2.5 (1.3) 3.9 (1.3) 2.0 (1.2) 3.2 (1.4) 2.2 (1.5) 63.8* 0.66 2.61Global score 3.7 (1.2) 1.7 (0.9) 3.6 (1.2) 1.3 (0.7) 3.0 (1.3) 1.4 (1.2) 155.4* 2.05 2.24

Beck Depression Inventory 32.7 (14.1) 15.8 (10.3) 30.5 (13.5) 13.4 (10.4) 28.3 (14.3) 18.5 (16.0) 98.5* 0.19 2.97State-Trait Anxiety

Inventory (Form-Y)60.2 (9.7) 52.1 (14.9) 60.5 (12.7) 48.3 (11.2) 54.2 (16.4) 49.8 (16.2) 21.7* 0.65 1.82

Temperament andCharacter InventoryNovelty Seeking 19.2 (7.5) 20.4 (6.6) 15.4 (4.4) 15.6 (4.6) 16.9 (5.4) 16.1 (5.7) 0.1 3.99£ 0.80Harm avoidance 21.6 (6.3) 18.3 (6.2) 23.0 (5.6) 19.3 (8.3) 22.6 (7.7) 20.5 (8.6) 22.0* 0.31 0.60Reward dependence 14.7 (4.6) 15.5 (4.2) 15.4 (3.5) 15.5 (3.6) 15.1 (3.1) 15.0 (3.0) 0.2 0.14 0.21Persistence 5.4 (1.6) 5.0 (2.0) 5.3 (2.0) 4.3 (2.2) 6.0 (1.9) 5.3 (2.1) 13.5* 1.26 0.70Self-directedness 18.0 (8.4) 20.9 (7.5) 18.4 (6.0) 23.2 (8.5) 25.4 (8.0) 27.1 (9.4) 8.5£ 6.74§ 0.75Cooperativeness 30.3 (6.7) 30.9 (6.2) 28.9 (5.5) 29.7 (8.5) 32.7 (5.5) 32.3 (4.8) 0.2 2.09 0.28Self-transcendence 14.6 (6.3) 12.2 (5.1) 14.3 (5.2) 12.0 (6.4) 12.7 (4.6) 11.1 (5.7) 12.2§ 0.62 0.16

Data are presented as mean (SD) or as 8number and (percentage).* p\ .001;§ p\ .01;£ P\ .05.a McNemar test as necessary

DALLE GRAVE ET AL.

374 International Journal of Eating Disorders 45:3 370–376 2012

ference not observed, to our knowledge, amongindividuals with bulimic-type eating disorders.5

These findings might be seen to be consistent withthe view that purging behaviors are inefficient asmeans of reducing caloric intake.38

The OBE and SBE groups were characterized bymore severe eating disorder psychopathology, inparticular significantly higher eating concern andlower self-directness at TCI, a finding also observedin a previous study on AN subtypes,39 than the no-RBE group. According to Cloninger et al.,40 self-directedness is a developmental process encom-passing several distinct aspects, including accep-tance of responsibility for one’s choices, identifica-tion of individually valued goals and purposes,resourcefulness, and self-acceptance. Lower self-directness, has been observed associated with pooroutcome in patients with eating disorder,41 andwith higher drop-out rates in patients with ANtreated with brief outpatient individual psychody-namic therapy.42

Importantly, however, in this study the threegroups had a similar dropout rate and time to drop-out, and responded similarly well to the inpatientCBT, with a significant improvement of BMI, eatingdisorder behaviors, eating disorder and generalpsychopathology, and of several personality fea-tures (namely, increased self-directness—a prog-nostic indicator of treatment efficacy—43 and harmavoidance, and decreased persistence and self-transcendence). By the end of treatment, all groupshad achieved a mean normal BMI, but the no-RBEgroup was more prone to regaining weight. Thislatter finding suggests that there may be limitedclinical utility in categorizing underweight eatingdisorder patients on the basis of the type or fre-quency of bulimic episodes.

In regression analysis, a higher frequency of sub-jective bulimic episodes and of episodes of intenseexercising prior to admission was associated with alower reduction in eating disorder psychopathologyfollowing treatment, after controlling for initial BMI,age, frequency of self-induced vomiting, laxative anddiuretic misuse, and exercising. In contrast, the fre-quency of objective bulimic episodes prior to admis-sion was not independently associated with anychange in eating disorder symptoms following treat-ment. According to these data, specific strategiesshould be developed to address subjective bulimicepisodes and intense exercising, to improve the out-come of our CBT-based inpatient treatment.

The strengths of the study are the inclusion ofseveral ED-NOS cases, a group scarcely evaluatedin previous research on bulimic episodes, and theassessment of bulimic episodes using the accurateEDE interview before and after treatment,8 but sev-

eral limitations should be also noted. First, becauseof the limited sample size we could not split ourOBE group according to the presence/absence ofsubjective bulimic episodes as used in other stud-ies.5 The preliminary analysis within the OBEgroup, showed a higher eating concern in patientswith subjective bulimic episodes which may bepartly explained by the loss of control over eatingthat characterizes both OBE and SBE patients.However, no other significant differences emergedbetween the two groups at baseline. Second, sam-ple size precluded a more stringent separation of‘‘regular binge eating’’ (‘‘once a week or more’’)from ‘‘nonregular binge eating’’ (‘‘less than once aweek’’) when assigning participants to groups. Thismay have had the effect of minimizing differencesbetween groups. Although the once a week thresh-old has been recently shown to capture individualswith clinically significant levels of binge eating psy-chopathology,27,28 our definition might have mini-mized differences between groups. Third, datawere derived from a single inpatient unit, mainlytreating adult underweight patients; external vali-dation is needed, and the results might not apply tounderweight outpatients or adolescent subjects orto individuals with AN- or AN-type EDNOS receiv-ing inpatient treatment in other regions. Fourth,life-time history data on objective and subjectivebulimic episodes were not fully available, and thepossible effects of crossover between the two typeson outcome cannot be evaluated. Fifth, the lack offollow-up precludes any inference on the long-term outcome of patients with OBE and SBE.

In conclusion, our data show that underweighteating disorder patients have similar treatmentresponse to an intensive inpatient program of CBTregardless of whether or not they report objectiveand/or subjective bulimic episodes. Althoughmethodological limitations preclude any firm con-clusions, the findings suggest that there may belimited clinical utility in categorizing underweighteating disorder individuals on the basis of the typeand frequency of bulimic episodes and that furtherinvestigation of the validity of distinguishing OBEand SBE among underweight eating disorderpatients is warranted. Finally, greater attention mayneed to be given to the role of SBE and excessiveexercise in improving treatment outcome for indi-viduals with AN and variants of AN.

Earn CE credit for this article!

Visit: http://www.ce-credit.com for additional infor-mation. There may be a delay in the posting of the article,so continue to check back and look for the section on Eat-ing Disorders. Additional information about the program isavailable at www.aedweb.org

OBJECTIVE AND SUBJECTIVE BINGE EATING IN EDS

International Journal of Eating Disorders 45:3 370–376 2012 375

References

1. American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders,4th ed. (text revision). Washington,

DC: American Psychiatric Association, 2000.

2. Beglin SJ, Fairburn CG. What is meant by the term ‘‘binge’’? Am

J Psychiatry 1992;149:123–124.

3. Telch CF, Pratt EM, Niego SH. Obese women with binge eating dis-

order define the term binge. Int J Eat Disord 1998;24:313–317.

4. Latner JD, Clyne C. The diagnostic validity of the criteria for

binge eating disorder. Int J Eat Disord 2008;41:1–14.

5. Mond JM, Latner JD, Hay PH, Owen C, Rodgers B. Objective and

subjective bulimic episodes in the classification of bulimic-type

eating disorders: Another nail in the coffin of a problematic

distinction. Behav Res Ther 2010;48:661–669.

6. Wolfe BE, Baker CW, Smith AT, Kelly-Weeder S. Validity and util-

ity of the current definition of binge eating. Int J Eat Disord

2009;42:674–686.

7. Fairburn CG, Cooper Z. The eating disorder examination (12th

ed). In: Fairburn CG, Wilson GT, editors. Binge Eating: Nature,

Assessment, and Treatment. New York: The Guilford Press,

1993, pp.317–360.

8. Pratt EM, Niego SH, Agras WS. Does the size of a binge matter?

Int J Eat Disord 1998;24:307–312.

9. Hay PJ, Fairburn CG, Doll HA. The classification of bulimic eat-

ing disorders: A community-based cluster analysis study. Psy-

chol Med 1996;26:801–812.

10. Tobin DL, Griffing A, Griffing S. An examination of subtype crite-

ria for bulimia nervosa. Int J Eat Disord 1997;22:179–186.

11. Stice E, Killen JD, Hayward C, Taylor CB. Age of onset for binge

eating and purging during late adolescence: A 4-year survival

analysis. J Abnorm Psychol 1998;107:671–675.

12. Kerzhnerman I, Lowe MR. Correlates of subjective and objective

binge eating in binge-purge syndromes. Int J Eat Disord

2002;31:220–228.

13. Keel PK, Mayer SA, Harnden-Fischer JH. Importance of size in

defining binge eating episodes in bulimia nervosa. Int J Eat Dis-

ord 2001;29:294–301.

14. Latner JD, Hildebrandt T, Rosewall JK, Chisholm AM, Hayashi K.

Loss of control over eating reflects eating disturbances and gen-

eral psychopathology. Behav Res Ther 2007;45:2203–2211.

15. Guss JL, Kissileff HR, Devlin MJ, Zimmerli E, Walsh BT. Binge

size increases with body mass index in women with binge-eat-

ing disorder. Obes Res 2002;10:1021–1029.

16. Niego SH, Pratt EM, Agras WS. Subjective or objective binge: Is

the distinction valid? Int J Eat Disord 1997;22:291–298.

17. Walsh BT, Fairburn CG, Mickley D, Sysko R, Parides MK. Treat-

ment of bulimia nervosa in a primary care setting. Am J Psychi-

atry 2004;161:556–561.

18. Hildebrandt T, Latner JD. Effect of self-monitoring on binge eat-

ing: Treatment response or ‘‘binge drift’’? Eur Eat Disord Rev

2006;14:16–22.

19. Latner JD, Wilson GT. Self-monitoring and the assessment of

binge eating. Behav Ther 2002;33:465–477.

20. Jacobs-Pilipski MJ, Wilfley DE, Crow SJ, Walsh BT, Lilenfeld LR,

West DS, et al. Placebo response in binge eating disorder. Int J

Eat Disord 2007;40:204–211.

21. Fairburn CG, Cooper Z, Bohn K, O’Connor ME, Doll HA, Palmer

RL. The severity and status of eating disorder NOS: Implications

for DSM-V. Behav Res Ther 2007;45:1705–1715.

22. Dalle Grave R. Terapia cognitivo comportamentale dei disturbi

dell’alimentazione durate il ricovero. Verona: Positive Press, 2005.

23. Dalle Grave R, Bohn K, Hawker D, Fairburn CG. Inpatient, day

patient and two forms of outpatient CBT-E. In: Fairburn CG,

editor. Cognitive Behavior Therapy and Eating Disorders. New

York: Guilford Press, 2008, pp.231–244.

24. Fairburn CG. Cognitive Behavior Therapy and Eating Disorders.

New York, NY: Guilford Press, 2008.

25. Mannucci E, Ricca V, Di Bernardo M, Rotella CM. Studio del

comportamento alimentare con una intervista strutturata: la

Eating Disorder Examination. Il Diabete 1996;8:127–131.

26. Wilson GT, Smith D. Assessment of bulimia nervosa: An evalua-

tion of the Eating Disorders Examination. Int J Eat Disord

1989;8:173–179.

27. Wilfley DE, Bishop ME, Wilson GT, Agras WS. Classification of

eating disorders: Toward DSM-V. Int J Eat Disord 2007;40

Suppl;S123–S129.

28. Wilson GT, Sysko R. Frequency of binge eating episodes in buli-

mia nervosa and binge eating disorder: Diagnostic considera-

tions. Int J Eat Disord 2009;42:603–610.

29. Cloninger CR, Svrakic DM, Przybeck TR, Wetzel RD. The Tem-

perament and Character Inventory (TCI): A Guide to Its Develop-

ment and Use. St Louis, MO: Center for Psychobiology of Per-

sonality, 1994.

30. Sato T, Hirano S, Narita T, Kusunoki K, Kato J, Goto M, et al.

Temperament and character inventory dimensions as a predic-

tor of response to antidepressant treatment in major depres-

sion. J Affect Disord 1999;56:153–161.

31. Fassino S, Abbate-Daga G, Amianto F, Leombruni P, Boggio S,

Rovera GG. Temperament and character profile of eating disor-

ders: A controlled study with the Temperament and Character

Inventory. Int J Eat Disord 2002;32:412–425.

32. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory

for measuring depression. Arch Gen Psychiatry 1961;4:561–571.

33. Gorsuch RL, Lushene RE. Manual for the State-Trait Anxiety In-

ventory (self evaluation questionnaire). Palo Alto, CA: Consult-

ing Psychologists Press, 1970.

34. Ramanaiah N, Franzen M, Schill T. A psychometric study of the

State-Trait Anxiety Inventory. J Pers Assess 1983;48:95–97.

35. Baggio A, Ferrari R, Partinico M, Vidotto G, Visentin M. Il Beck

Depression Inventory per la valutazione della depressione nel

dolore cronico. Il contributo degli ‘‘item’’ somatici. Int J Pain

Ther 1997;7:4–11.

36. Lazzari R, Pancheri P. Questionario di Valutazione dell’Ansia di

Stato e di Tratto (State-Trait Anxiety Inventory). Firenze: Organ-

izzazioni Speciali, 1980.

37. Bulik CM, Berkman ND, Brownley KA, Sedway JA, Lohr KN. Ano-

rexia nervosa treatment: A systematic review of randomized

controlled trials. Int J Eat Disord 2007;40:310–320.

38. Kaye WH, Weltzin TE, Hsu LK, McConaha CW, Bolton B. Amount

of calories retained after binge eating and vomiting. Am J Psy-

chiatry. 1993;150:969–971.

39. Klump KL, Bulik CM, Pollice C, Halmi KA, Fichter MM, Berrettini

WH, et al. Temperament and character in women with ano-

rexia nervosa. J Nerv Ment Dis 2000;188:559–567.

40. Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological

model of temperament and character. Arch Gen Psychiatry

1993;50:975–990.

41. Bulik CM, Sullivan PF, Joyce PR, Carter FA, McIntosh VV. Predic-

tors of 1-year treatment outcome in bulimia nervosa. Compr

Psychiatry 1998;39:206–214.

42. Fassino S, Abbate-Daga G, Piero A, Rovera GG. Dropout from

brief psychotherapy in anorexia nervosa. Psychother Psycho-

som 2002;71:200–206.

43. Fassino S, Amianto F, Gramaglia C, Facchini F, Abbate Daga G.

Temperament and character in eating disorders: Ten years of

studies. Eat Weight Disord 2004;9:81–90.

DALLE GRAVE ET AL.

376 International Journal of Eating Disorders 45:3 370–376 2012