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Binge Eating: Nature, Assessment and Treatment

ARTICLE JANUARY 1993

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Christopher G Fairburn
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Binge Eating:
Nature, Assessment , & Treatment

C. G. Fairburn, & G. T. Wilson (1993)

New York: The Guilford Press

Classification: Anorexia Nervosa

DSM-IV 307.1 Diagnostic Features

A. Refusal to maintain 85% of normal weight

for sex, age and height or failure to make
expected weight gains.
B. Intense fear of gaining weight or
becoming fat even though under weight
C. Disturbed perception of body weight
and/or appearance or denial of the
seriousness of their condition.
D. Postmenarcheal females are amenorrheic.

Classification: Anorexia Nervosa

DSM-IV 307.1 Diagnostic Features

Anorexia is a misnomer because loss of

appetite is rare.
Food restriction is common
Exercise can be excessive [actigraphy]
[No outpatient activity studies have been
conducted to verify suspected patterns of
hyperactivity]
[Starvation eventually reduces activity level
to well below normal levels]
[Activity level increases then correlate with
weight gain in hospital]
3

Classification: Anorexia Nervosa

DSM-IV 307.1 Subtypes

Restricting Type
Weight loss is accomplished primarily
through dieting, fasting, or excessive
exercise.
Binge-Eating/Purging Type
Most who binge eat also purge via selfinduced vomiting
Misuse of laxatives, diuretics, or enemas
Some purge after eating small amounts
These behaviors occur at least weekly
4

Classification: Bulimia Nervosa

DSM-IV 307.51 Diagnostic Features

A. Recurrent episodes of binge eating.

(1) Consuming more in 2 hours that most
people would.
(2) Feeling out of control while eating.
B. Recurrent attempts to prevent weight gain
through vomiting, laxatives, diuretics,
enemas, or fasting.
C. A and B occur at least twice a week for at
least 3 months.
5

Classification: Bulimia Nervosa

DSM-IV 307.51 Diagnostic Features

D. Self-evaluation is unduly influence by

body shape and weight.
E. The disturbance does not occur
exclusively during episodes of Anorexia
Nervosa

Classification: Bulimia Nervosa

DSM-IV 307.51 Subtypes

Purging Type
Self-induces vomiting or misuse of
laxatives, diuretics, or enemas.
Nonpurging Type
Engages in fasting and/or excessive
exercise but not purging.

Classification: Eating Disorder Not Otherwise

Specified DSM-IV 307.50
1. For females, all of the criteria for
Anxorexia Nervosa are met except that the
individual has regular menses.
2. All of the criteria for Anorexia Nervosa are
met except that, despite significant weight
loss, the individuals current weight is in the
normal range.
3. All of the criteria for Bulimia Nervosa are
met except that the binge eating and
inappropriate compensatory mechanisms
occur at a frequency of less than twice a
week or for a duration of less than 3 months. 8

Classification: Eating Disorder Not Otherwise

Specified DSM-IV 307.50
4.The regular use of inappropriate
compensatory behavior by an individual of
normal body weight after eating small
amounts of food (e.g., self-induced vomiting
after the consumption of two cookies).
5. Repeatedly chewing and spitting out, but
not swallowing, large amounts of food.
6. Binge-eating disorder: recurrent episodes
of binge eating in the absence of the regular
use of inappropriate compensatory behaviors
characteristic of Bulimia Nervosa (cf. p 729)
9

Research Criteria for

Binge-eating Disorder
A. Recurrent episodes of binge eating.
1. Eating a large amount of food in 2 hrs.
2. Feeling a lack of control. Unable to stop
eating or control how much is eaten.
B. Binge-eating is associated with three or
more of the following:
1. Eating much more rapidly than normal
2. Eating until uncomfortably full
3. Eating large amounts of food when not
hungry
10

Research Criteria for

Binge-eating Disorder
4. Eating along because of being
embarrassed about how much one is eating
5. Feeling disgusted with oneself,
depressed, or very guilty after overeating
C. Marked distress regarding binge eating
D. Binge eating occurs at least 2 days per week
for 6 months.
E. Binge eating is not associated with purging,
fasting, excessive exercise. Anorexia Nervosa
and Bulimia have been excluded.
11

Pharmacotherapy:
Antidepressants
Some superiority over placebo for reducing
frequency and intensity of binge eating
episodes, food preoccupation, and
depression.
Imipramine & Desipramine are best studied.
Amitriptyline has been effective in promoting
weight gain.
Monoamine Oxidase Inhibitors (MAOI)
(phenelzine & isocarboxazide) are superior to
placebo for bulimia.
SSRI (fluoxetine) reduces binge eating.
12

Eating Disorder Exam (12th Ed.)

Restraint Subscale
Restraint Over Eating
Over the past 4 weeks have you been
consciously trying to restrict what you eat,
whether or not you have succeeded?
Has this been to influence your shape or
weight?
[Rate number of days on a 0 to 6 scale]
[Rate if successful or not on 0 to 6 scale]
13

Eating Disorder Exam (12th Ed.)

Restraint Subscale
Avoidance of Eating
Over the past 4 weeks have you gone for
periods of 8 or more waking hours without
eating anything?
Has this been to influence your shape or
weight?
[Rate the number of days on a 0 to 6 scale]
[Abstinence must be at least partly selfimposed.]
14

Eating Disorder Exam (12th Ed.)

Restraint Subscale
Empty Stomach
Over the past 4 weeks have you wanted
your stomach to be empty?
Has this been to influence your shape or
weight?
[Rate the number of days on a 0 to 6 scale]
[Should not be confused with a desire for
the stomach to feel empty or be flat.]
15

Eating Disorder Exam (12th Ed.)

Restraint Subscale
Food Avoidance
Over the past 4 weeks have your tried to
avoid eating any foods that you like,
whether or not you have succeeded?
Has this been to influence your shape or
weight?
[Rate the number of days on a 0 to 6 scale]
[Do not count drinks as food]
16

Eating Disorder Exam (12th Ed.)

Restraint Subscale
Dietary Rules
Over the past 4 weeks have you tried to
follow certain definite rules regarding your
eating, for example, a calorie limit, preset
quantities of food, or rules about what you
should eat or when you should eat?
Have their been occasions when you have
been aware that you have broken a dietary
rule that you have set for yourself?
17

Eating Disorder Exam (12th Ed.)

Restraint Subscale
Dietary Rules
What are these rules? Why have you tried
to follow them? Have they been designed
to influence your shape or weight?
Have they been definite rules or general
principles? Examples of definite rules
would be I must not eat eggs or I must
not eat cake, whereas you could have the
general principle I should try to eat healthy
food.
[Rate rule following on a 0 to 6 scale.]
18

Eating Disorder Exam (12th Ed.)

Eating Concern Subscale
Preoccupation with Food, Eating, or Calories
Over the past 4 weeks have you spent
much time between meals thinking about
food, eating, or calories?
Has thinking about food, eating, or calories
interfered with your ability to concentrate?
How about concentrating on things that
you are interested in, for example, reading,
watching TV, or following a conversation?
[Rate concentration impairment on a 0 to 6
scale]
19

Eating Disorder Exam (12th Ed.)

Eating Concern Subscale
Fear of Losing Control Over Eating
Over the past 4 weeks have you been
afraid of losing control over eating?
[Rate the number of days on which definite
fear has been present on a 0 to 6 scale]
Social Eating
Over the past 4 weeks have you been
concerned about other people seeing you
eat?
[Rate average for past month on a 0 to 6
scale.]
20

Eating Disorder Exam (12th Ed.)

Eating Concern Subscale
Eating in Secret
Over the past 4 weeks have you eaten in
secret?
[Rate the number of days on a 0 to 6 scale]
Guilt About Eating
Over the past 4 weeks have you felt guilty
after eating?
Have you felt that you have done
something wrong? Why?
On what proportion of the times that you
have eaten have you felt guilty?
[Rate on a 0 to 6 point scale]
21

Eating Disorder Exam (12th Ed.)

Weight Concern Subscale
Desire to Lose Weight
Over the past 4 weeks have you wanted to
lose weight?
Have you had a strong desire to lose
weight?
[Rate number of days of strong desire]
Reaction to Prescribed Weighing
How would you feel if you were asked to
weigh yourself once each week for the next
4 weeks?
[0 = No Reaction, 6 = Positive Reaction]
22

Eating Disorder Exam (12th Ed.)

Shape Concern Subscale
Dissatisfaction with Shape
Over the past 4 weeks have you been
dissatisfied with your shape?
Have you been so dissatisfied that it has
made you unhappy?
[Rate only body shape not tone]
[Rate 4, 5, or 6 only if distress is present]
23

Eating Disorder Exam (12th Ed.)

Shape Concern Subscale
Preoccupation with Shape or Weight
Over the past 4 weeks have you spent
much time thinking about your shape or
weight?
Has thinking about your shape or weight
interfered with your ability to concentrate?
How about concentrating on things you are
interested in, for example, reading,
watching TV, or following a conversation?
[Rate intrusive thoughts about shape or
weight on a 0 to 6 points scale.]
24

Eating Disorder Exam (12th Ed.)

Shape Concern Subscale
Importance of Shape
Over the past 4 weeks has your shape been
important in influencing how you feel about (judge,
think, evaluate) yourself as a person?
If you imagine the things that influence how you
feel about (judge, think, evaluate) yourself - such
as (your performance at work, being a parent,
your marriage, how you get on with other people) and put these things in order of importance, where
does your shape fit in?
If over the past 4 weeks your shape had changed
in any way, would this have affected how you feel
about yourself?
Is it important that your shape does not change?
[Rate on a 0 to 6 point scale]
25

Eating Disorder Exam (12th Ed.)

Shape Concern Subscale
Importance of Weight
Over the past 4 weeks has your weight been
important in influencing how you feel about (judge,
think, evaluate) yourself as a person?
If you imagine the things that influence how you
feel about (judge, think, evaluate) yourself - such
as (your performance at work, being a parent,
your marriage, how you get on with other people) and put these things in order of importance, where
does youre your weight fit in?
If over the past 4 weeks your weight had changed
in any way, would this have affected how you feel
about yourself?
Is it important that your weight does not change?
[Rate on a 0 to 6 point scale]
26

Eating Disorder Exam (12th Ed.)

Shape Concern Subscale
Fear of Weight Gain
Over the past 4 weeks have you been
afraid that you might gain weight (or
become fat)?
[Rate number of days on a 0 to 6 scale]

27

Eating Disorder Exam (12th Ed.)

Shape Concern Subscale
Discomfort Seeing Body
Over the past 4 weeks have you felt
uncomfortable seeing your body, for
example, in the mirror, in shop window
reflections, while undressing, or while
taking a bath or shower?
Have you avoided seeing your body?
Why?
[Discomfort should be about overall
appearance, not from a specific body part
or from modesty]
[Rate discomfort on a 0 to 6 point scale]
28

Eating Disorder Exam (12th Ed.)

Shape Concern Subscale
Avoidance of Exposure
Over the past 4 weeks have you felt
uncomfortable about others seeing your
body, for example, in communal changing
rooms, when swimming, or when wearing
clothes tha show your shape? What about
your partner or friends seeing your body?
Have you avoided such situations? Why?
[Discomfort should be about overall
appearance, not from a specific body part
or due to modesty.]
[Rate discomfort on a 0 to 6 point scale]
29

Eating Disorder Exam (12th Ed.)

Shape Concern Subscale
Feelings of Fatness
Over the past 4 weeks have you felt fat?
[Rate number of days on a 0 to 6 scale]
Flat Stomach
[Omit this item is subject is obviously
overweight and rate 7]
Over the past 4 weeks have you had a
definite desire to have a flat stomach?
[Rate number of days on a 0 to 6 scale]
Measure persons height and weight.
30

Eating Disorder Exam Diagnostic Items

Bulimic episodes and other episodes of
overeating.
Dietary restriction outside bulimic episodes.
Self-Induced vomiting.
Laxative misuse.
Diuretic misuse.
Intense exercising to control shape or weight.
Abstinence from extreme weight-control
behavior.
Importance of shape.
Importance of weight.
Fear of weight gain.
Feelings of fatness.
Maintained low weight.
31
Menstruation.

Eating Disorder Exam (12th Ed.)

Reliability Data
Interrater Reliability
Kappas > .75 for most items.
Kappas > .70 for 3 items
Test-Retest Reliability
No studies to date
Internal Consistency (Coefficient Alpha)
Ranged from .68 to .90
32

Eating Disorder Exam (12th Ed.)

Validity Data
Discriminant Validity
Cooper et al. (1989). EDE discriminates
eating disordered from normal controls.
Fairburn & Cooper (1992). EDE
discriminates bulimics from normals.
Concurrent Validity
Moderate (unreported) correlations with
eating diaries for past week. EDE covers
past month.
Highly related to vomiting reports.
33

CBT Treatment Manual

Targeted for 20 sessions.
Focus is on present and future vs. past.
Emphasis is on factors that maintain eating
problems vs. etiological issues.
Three treatment stages:
1. Presenting the cognitive view and
replace binge eating with stable eating.
2. Elimination of dieting. Emphasis on
problematic thoughts, beliefs, and values.
3. Maintenance is prime concern.
34

CBT Treatment Manual

Stage 1 (Sessions 1 & 2)
Two major aims:
1. Explain the rationale underlying CBT
2. Replace binge eating with stable eating
Aims of stage 1
Establish a therapeutic relationship
Educate pt regarding CBT
Establish weekly weighing plan
Educate pt regarding weight regulation,
adverse effects of dieting, physical
consequences of binge eating, vomiting,
and laxative use.
35

CBT Treatment Manual

Stage 1 (Sessions 3 to 8)
Introduce principal behavioral strategies for
regaining control over eating.
Set realistic behavioral goals for each week.
Clarify cognitive view of eating disorders.
Educate pt. About weight and eating.
1. Review BMI tables (kg/m2) [pressure]
Below 18 is underweight
20 to 27 is healthy
27 or more is overweight
2. Review physical consequences of binge
36
eating, vomiting, and laxative abuse.

CBT Treatment Manual

Stage 1 (Sessions 3 to 8)
3. Review ineffectiveness of vomiting and
laxative abuse as means of weight control.
4. Review adverse effects of dieting
Not eating for long periods of time
Focused on in Stage 1
Not eating certain foods
Restricting total amount of food eaten
Rule breaking is understood as personal
failure resulting in overeating.
37

CBT Treatment Manual

Stage 1 (Sessions 3 to 8)
Giving advice regarding eating.
1. Prescriptive pattern of regular eating.
This is the most important treatment element.
Schedule 3 planned means and 2 planned
snacks.
Not more than 3 hours between meals or
snacks except for sleeping.
Meals and snacks take precedence over all
other activities.
Do not eat in between means & snacks.
38

CBT Treatment Manual

Stage 1 (Sessions 3 to 8)
Introduce in phases with most disturbed pts.
Begin with their least disturbed eating times.
Do NOT count calories.
Just eat average portions.
2. Engage in pleasurable activities that are
incompatible with binge eating (telephoning or
visiting friends, exercise, bath/shower).
Anticipate times when binge eating occurs
and then engage in incompatible behavior.
3. Stimulus control
Eat in one distinctive place
39

CBT Treatment Manual

Stage 1 (Sessions 3 to 8)
Do not engage in other activities (reading,
TV) while eating.
Leave some food on your plate.
Discard leftovers.
Put dangerous foods in a safe place. One
that is out of sight and difficult to get to.
Carefully plan food shopping.
Do not shop when hungry.
Buy food that requires preparation.
Carry a limited amount of money.
40

CBT Treatment Manual

Stage 1 (Sessions 3 to 8)
Advice regarding vomiting
Vomiting often stops when overeating stops.
Choose meals and snacks you will not vomit.
Engage in distracting activities when feeling the
urge to vomit.
Joint Interview with Patients Friends & Relatives
Brings problem out in the open. Removes
secrecy. Coming out
Have pt explain principles and rationale of
treatment to see if they fully understand.
Helps stimulate social support.
41

CBT Treatment Manual

Stage 2 (Sessions 9 to 16)

General Principles
Continued emphasis on regular eating.
Continued weekly weighing.
Further discussion of dieting.
Focus on concerns about shape and weight and
other cognitive distortions.
Dieting
Further reduce or eliminate dieting.
Emphasize relationship between dieting and binge
eating.
42

CBT Treatment Manual

Stage 2 (Sessions 9 to 16)
Falling off diet causes feeling out of control.
Loss of control causes binge eating.
Lack of dieting does not result in weight gain
because the absence of binge eating greatly
lowers caloric intake; below that of normal eating.
Dieting by not eating was covered in Stage 1.
Dieting by avoiding specific foods and calorie
restriction are covered in Stage 2.
Make a hierarchy of avoided food items.
Systematically introduce them into pts diet.
Anxiety hierarchy over food.
43

CBT Treatment Manual

Stage 2 (Sessions 9 to 16)
Enhancing Problem Solving Skills
Identify external stressors associated with over
eating.
Discuss alternative coping methods.
Addressing Concerns About Shape & Weight
Relapse is likely unless these issues are
successfully addressed.
1. Write down a verbatim thought associated
with gaining 2 or more pounds.
2. Marshall arguments and evidence to support
this thought.
44

CBT Treatment Manual

Stage 2 (Sessions 9 to 16)
3. Marshall arguments and evidence against
this thought.
4. Reach a reasoned conclusion about this
thought and behave accordingly.
Address other cognitive distortions
Dichotomous reasoning
Extreme perfectionism
Low self-esteem
45

CBT Treatment Manual

Stage 3 (Sessions 17 to 19)
Consists of 3 interviews at 2 week intervals.
Primary aim is maintenance.
Emphasize continued improvement in patients
who are still learning new behaviors.
Discuss termination and future plans.
Construct relapse plans.
Anticipate relapse.
Prepare to deal with it.
46

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