REGULAR ARTICLE

Maintenance of Binge Eating through Negative Mood:

A Naturalistic Comparison of Binge Eating Disorder
and Bulimia Nervosa
Anja Hilbert, PhD1*
Brunna Tuschen-Cafer, PhD2

ABSTRACT
Objective: To examine negative mood
as a proximal antecedent and reinforcing
condition of binge eating in binge eating
disorder (BED) and bulimia nervosa (BN).
Method: Using an ecological momentary assessment design, 20 women with
BED, 20 women with BN, and 20 nonclinical control women were recruited from
the community, provided with a portable
minicomputer, and asked to rate their
mood and list their thoughts at randomlygenerated beep sounds and before, during, and after episodes of eating.
Results: In both eating disorder groups
mood before binge eating was more negative than before regular eating and at

Introduction
Maintenance factors are involved in symptom persistence of psychological disorders, making them
central targets of psychological treatment. The
maintenance of binge eating disorder (BED), a provisional diagnosis in need of further study,1 is only
preliminarily understood. BED is characterized
through recurrent binge eating that occurs, in contrast to binge eating in bulimia nervosa (BN), in the
absence of regular compensatory behaviors to prevent weight gain, such as fasting or vomiting. As
emphasized by several maintenance theories, binge
eating may be maintained, among other factors,
through difculties in regulating negative affect.25
Binge eating is assumed to proximally occur under

Accepted 25 April 2007

Supported by Tu 78/3-1 from the German Research Foundation
and by 01GP0491 from the German Ministry of Education and
Research.
*Correspondence to: Anja Hilbert, Department of Psychology,
Philipps University of Marburg, Gutenbergstrasse 18, D-35032
Marburg, Germany. E-mail: hilbert@staff.uni-marburg.de
1
Department of Psychology, Philipps University of Marburg,
Gutenbergstrasse 18, Marburg, Germany
2
Department of Psychology, University of Bielefeld, Bielefeld,
Germany
Published online 15 June 2007 in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/eat.20401
C 2007 Wiley Periodicals, Inc.
V

random assessment. Binge eating was

followed by a deterioration of mood. The
BED group revealed less antecedent negative mood than the BN group and less
concomitant negative cognitions about
food/eating and stress.
Conclusion: Affect regulation difculties likely lead to binge eating in both
disorders, but binge eating may not be
effective for regulating overall mood.
C 2007 by Wiley Periodicals, Inc.
V
Keywords: ecological momentary assessment; affect regulation; binge eating;
binge eating disorder; bulimia nervosa

(Int J Eat Disord 2007; 40:521530)

aversive affective states, especially antecedent negative mood, and to provide temporary relief from
this negative mood, thereby reinforcing binge eating behavior. Yet, empirical evidence on the maintenance of binge eating through negative mood in
BED remains incomplete.
Negative mood was supported as an antecedent
of binge eating in BED by a number of studies
using retrospective assessment,69 concurrent assessment in the naturalistic environment,1014 and
experimental tests.15,16 In contrast, mixed evidence
has been found from the few studies examining the
course of negative mood related to binge eating: A
retrospective study found lower levels of anxiety,
but not of depression, after binge eating than
before binge eating in treatment-seeking women
with BED.7 Further, an ecological momentary assessment (EMA) study17 involving concurrent assessment of binge-related experiences in subclinical binge eaters found less pleasantness prior to
than during binge eating, and the pleasantness
decreased again after binge eating.18 These results
suggest that binge eating may indeed serve to
reduce negative affect or lead to an increase of positive affect. In contrast, two EMA studies found
more negative mood after binge eating than prior
to binge eating in treatment-seeking women with
BED14 and subclinical binge eaters.19 Although
these inconsistent ndings may be because of

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521

HILBERT AND TUSCHEN-CAFFIER

methodological differences (e.g., retrospective

versus concurrent assessment perspective, time
points of assessment, operationalization of negative mood), it remains unclear whether binge eating in BED leads to a reduction or an increase of
negative mood; whether mood changes are a consequence or rather a concomitant experience of
binge eating; whether the mood course is specic
for binge eating in BED or whether it also occurs
in the context of regular episodes of eating; and
whether it is specic for individuals with BED or
whether it also emerges in non-eating disordered
individuals. Addressing these questions could
enhance understanding of the role that affect
regulation difculties have in the maintenance of
binge eating in this disorder.
When investigating mood and binge eating in
BED, it deserves consideration that mood related
to binge eating subsumes a variety of emotional
qualities7,14,20 and is likely associated with a range
of cognitions, for example, eating concerns, shape
and weight concerns, or stress-related cognitions.69,14,21 Specifying the cognitive content
present in the context of binge eating could provide
information about the sources of mood related to
binge eating and about the proximal relevance of
other proposed maintenance factors of binge eating, for example, eating concerns, negative body
image, and life stress.24
In addition, whether the maintenance of binge
eating through negative affect differs in BED from
that in BN deserves examination. One retrospective
study found binge eating in BED and BN to be
equally preceded by negative mood states.9 Yet,
individuals with BED reported more positive concomitant experiences related to the hedonic quality
of food and less post-binge anxiety than individuals
with BN, advocating for greater positive and negative reinforcement of binge eating through mood
states in BED. In BN, some studies found compensatory behaviors rather than binge eating to serve
affect regulation purposes; however, others did
not.22,23 Given the scant comparative evidence and
in light of current discussions on eating disorder
nosology,24,25 it is indicated to compare putative
proximal maintenance factors of binge eating in
both disorders.
In this context, the goal of the present study was
to investigate maintenance of binge eating through
negative mood in BED compared with a clinical
control group of BN and a non-clinical control
group (NC). It was hypothesized (1) that negative
mood is an antecedent of binge eating in both BED
and BN; (2) that binge eating is associated with a
decrease of negative mood in BED and BN; (3) that
binge eating in BED is associated with a stronger
522

decrease of negative mood than binge eating in

BN; and that (4) concerning cognitive content,
individuals with BED exhibit less negative food/
eating-related and less stress-related cognitions
than individuals with BN over the course of binge
eating.26 We additionally assumed that negative
cognitions about body image are not proximally
related to binge eating in either disorder.27 We
chose an EMA design for random- and event-sampling of mood and cognitions at the time of their
occurrence in the naturalistic environment.28 EMA
has proven feasible in the behavioral assessment
of eating and weight-related disorders and is
appreciated for ecological validity and reliability,
in particular, through limiting memory and reporting biases inherent to retrospective self-report.17
Assessment was based on mood ratings and
thought sampling of negative cognitions. Thought
listing, used for thought sampling in many mental
disorders and psychological problems, allows for
immediate recording of thoughts in a free response
format without priming probands with predened
categories of thinking.29,30

Method
Sample
The study sample consisted of 20 women diagnosed
with BED, 20 non-eating-disordered women for NC, and
20 women diagnosed with BN as a clinical control group.
Ethical approval for the conduct of this study was
granted by the German Psychological Societys ethics
committee. All participants were recruited from the community through newspaper announcements and public
notices, offering 80.00 for participation. A total of 143
volunteers was screened in a telephone interview to
determine diagnostic criteria of BED and BN according
to the Diagnostic and Statistical Manual of Mental Disorders DSM-IV (inclusion criteria) and chronic physical
diseases (exclusion criteria).1 Exclusion criteria for NC
participants included a diagnosis of a current mental disorder, and current and lifetime eating disorders or symptoms of disordered eating. The BED and the NC group
were matched for age and body mass index (BMI, kg/
m2). Following the telephone screening, 91 volunteers
were invited to participate in a diagnostic interview
(63.6% out of 143), and of these, 78 volunteers attended
(54.4% out of 143). Interview measures consisted of the
structured clinical interviews Eating Disorder Examination (EDE)31,32 used for eating disorder diagnosis and the
Mini-DIPS33 used for psychiatric diagnosis according to
the DSM-IV. Subsequently, 18 women were excluded
because they did not meet diagnostic requirements, leav-

International Journal of Eating Disorders 40:6 521530 2007DOI 10.1002/eat

MAINTENANCE OF BINGE EATING THROUGH NEGATIVE MOOD

TABLE 1.

Sociodemographic and clinical characteristics

Binge Eating
Disorder (N 20)

Sociodemographic characteristics
Age (years)
Body mass index (kg/m2)
Education
Low
High
Clinical characteristics
EDE-Restraint
EDE-Eating concern
EDE-Weight concern
EDE-Shape concern
SCL-90-R-GSI, T-scores

Bulimia Nervosa
(N 20)

Non-Clinical Control
Group (N 20)

M
36.65a
32.99a

SD
10.12
6.99

M
24.47b
23.13b

SD
5.83
4.61

M
36.30a
32.18a

SD
9.43
6.53

Test
F(2, 57) 12.24*
F(2, 56) 15.95*

n
14
6

%
70.0
30.0

n
9
11

%
45.0
55.0

n
9
11

%
45.0
55.0

v2(2, N 60) 3.35

M
2.26a
1.17a
3.32a
3.42a
65.72a

SD
1.41
1.06
1.10
0.98
13.30

M
3.55b
3.27b
4.27a
4.14a
73.28b

SD
1.32
1.22
1.44
1.60
6.35

M
1.10c
0.09c
1.49b
1.19b
46.27c

SD
1.13
0.13
1.07
0.95
5.08

Test
F(2, 57) 18.09*
F(2, 57) 59.78*
F(2, 57) 27.17*
F(2, 57) 31.98*
F(2, 52) 45.21*

Notes: M, mean; SD, standard deviation; n, %, frequencies; EDE, Eating Disorder Examination; SCL-90-R, Symptom Checklist-90-Revised; GSI, global severity index.
Education: low, no school degree or degree with less than 13 years of education; high, degree with 13 years of education or university degree.
a,b,c
Different superscripts indicate signicant group differences in univariate GLM and post hoc Bonferroni tests or v2 tests, p < .05.
* p < .05.

ing a total of N 60 volunteers for participation in the

study (42.0% out of 143).
Eating-disordered participants fullled DSM-IV diagnostic criteria of either BED or BN.1 Sociodemographic
and clinical characteristics are presented in Table 1. Participants with BED were signicantly older and had a
greater BMI (kg/m2) than participants with BN (p < .05),
which corresponds to epidemiological data.34 Groups did
not differ on education (p > .05). As expected, participants with BED demonstrated higher scores on all EDE
subscales than participants from the NC group but lower
scores on Restraint and Eating Concern than participants
with BN (all p < .05).35 Also, participants with BED and
BN displayed a greater global severity index (GSI) score
on the Symptom Checklist-90-Revised than individuals
from the NC group (SCL-90-R),36,37 and the GSI score
was higher in the BN group than in the BED group (all
p < .05). Two participants in the BED group (10.0% out of
20) and four participants in the BN group (20.0% out of
20) reported being in treatment for a psychological or
weight problem.

Procedure
The EMA procedure took place on two consecutive
days (day 1, day 2). Assessment days were counterbalanced within each group by assigning 23 probands per
group to each of the seven possible combinations of two
consecutive days of the week (e.g., Monday/Tuesday,
Tuesday/Wednesday). On the day prior to the rst assessment day, participants were provided with a portable
minicomputer (BASIC-stamp II, Wilke Technology) and a
diary booklet for paper and pencil assessment of psychological variables and food intake. Participants received a
standardized 20-min training on all EMA procedures.

For random-sampling of mood and cognitions, the

minicomputer generated 32 beep sounds per day in random intervals ranging from 10 to 50 min. This corresponded to a mean interval between beep sounds of 30
min for a period of 16 waking hours per day. Participants
were asked to switch on the computer after waking up
and to respond to every beep sound by pushing an acknowledgment button on the minicomputer and lling
out a mood and cognition protocol in the diary booklet
(\random protocol"). In case a participant failed to press
a key following a beep, an alarm procedure started until
an acknowledgment keypress was performed. For compliance check, random intervals and reaction times were
saved on the minicomputer.
For event-sampling of mood and cognitions in the
context of eating episodes, participants were instructed
to rate their mood and list their thoughts before, during,
and after each episode of eating as well as to monitor
their intake on the diary booklet (\eating protocol"). A
keypress was required prior to every episode of eating;
the number of eating episodes was charged against the
total number of beep sounds per day so that every participant had to ll out exactly 32 protocols per day.
When returning the minicomputer and the diary, a
post-investigative interview was conducted to provide
the possibility of counseling for any acute stress
responses that participation in the study might have
caused. In addition, participants were asked to self-rate
compliance with the procedure, invasiveness of the procedure, and representativeness of eating behavior on
assessment days for overall eating behavior. Finally, information was gathered on physical conditions with a
potential inuence on mood and/or appetite during the
assessment period, for example, menstrual cycles and
medication intake (see Control Variables).

International Journal of Eating Disorders 40:6 521530 2007DOI 10.1002/eat

523

HILBERT AND TUSCHEN-CAFFIER

TABLE 2.

Control variables of the ecological momentary assessment procedure

Binge Eating
Disorder (N 20)

Minicomputer
Acknowledgment key
presses (n per day)
Reaction times (s)
Protocols
Total protocols (n per day)
Random protocols (n per day)
Total eating protocols
(n per day)
Thought listing coding units
(n per day)
Post-investigative interview
Compliance, 06
Representativeness of
eating behavior, 06
Invasiveness, 06
Menstrual status, menstruating
Mood and/or appetite-affecting
medication

Non-Clinical
Control Group
(N 20)

Bulimia
Nervosa (N 20)

Test

SD

% (out of n)

SD

% (out of n)

SD

% (out of n)

F(2, 57)

29.55a

3.63

92.3 (32)

24.83b

4.38

77.6 (32)

29.73a

3.27

92.9 (32)

10.79*

22.00a

13.74

41.40b

25.72

36.65a

16.08

29.55a
24.35a
5.20

3.63
3.07
1.27

24.83b
20.70b
4.13

4.38
4.43
2.25

29.73a
24.78a
4.95

3.27
4.20
1.71

92.3 (32)
82.4 (30)
17.6 (30)

77.6 (32)
83.4 (25)
16.6 (25)

5.54*
92.9 (32)
83.4 (30)
16.6 (30)

10.79*
6.45*
1.98

113.68

68.17

111.53

42.46

101.38

37.25

0.33

4.85
4.05

0.93
1.54

4.60
4.05

1.00
1.61

4.75
4.90

0.97
1.37

0.34
2.12

2.58ab

0.78

2.75a

1.18

1.70b

1.09

5.95*
v2 (2, N 60)
5.22
3.80

10.0 (2)
60.0 (12)

40.0 (8)
40.0 (8)

20.0 (4)
30.0 (6)

Notes: M, mean; SD, standard deviation; % (out of n keypresses or protocols, respectively).

a,b
Different superscripts indicate signicant group differences in univariate GLM and post hoc Bonferroni tests, p < .05.
Self-rated compliance, representativeness of eating behavior, and invasiveness (0 very low, 6 very high).
* p < .05.

Measures
Mood Ratings. Mood was rated on seven-point rating
scales ranging from 0 very bad to 6 very good at each
random beep and prior to, during, and after each episode
of eating.
Thought Sampling of Negative Cognitions on Food/Eating, Stress, and Body Image. For cognitive assessment
through thought listing, participants were asked to list all
thoughts that had entered their mind during the previous
5 min at each random beep and prior to, during, and after eating. For data reduction, thought listing protocols
were subjected to a quantitative content analysis. Based
on predened coding rules, idea units, that is, sentence
parts constituting a distinctive meaning, were determined as coding units for the content analysis. Two independent raters who were blind concerning group assignment divided the thought listing protocols into idea
units. Average inter-rater agreement on coding units was
97.9%. Based on predened coding rules, coding units
were then classied according to their content and valence. For content classication, coding units were classied according to whether they contained food/eatingrelated cognitions (e.g., about hunger, appetite, loss of
control over eating, control over eating), stress-related
cognitions (e.g., about excessive demands, pain, tension,
exhaustion), body-related cognitions (e.g., about body
shape, body weight), or non-target cognitions (i.e., other
cognitions). For valence classication, coding units were
classied according to whether they contained negative,

524

positive, or neutral valence. For an assessment of interrater agreement on the content and valence classications, all idea units were classied by the two independent raters, blind to group assignment. The mean percentage agreement between them was 92.6% for the content
and valence classications, ranging from 66.7% to 95.3%.
Thus, coding reliability was acceptable.
Self-Monitoring of Food Intake. Participants were
asked to report on the diary booklet type and quantity of
the foods they consumed; start and end of an episode;
whether or not they qualied an eating episode as binge
eating episode given the DSM-IV denition (i.e., consumption of a large amount of food in a discrete period
of time, accompanied by a sense of loss of control over
eating; 0 no, 1 yes);1 and whether or not and what
kind of inappropriate compensatory behavior they used
(e.g., self-induced vomiting, use of laxatives, use of diuretics, excessive exercise; 0 no, 1 yes). Food intake
was converted into energy intake (in kcal) using the
nutritional software PRODI1 4 (Nutri-Science).
Control Variables
Control variables are presented in Table 2. The number and timepoints of acknowledgment keypresses on
the minicomputer corresponded exactly to the number
and timepoints of completed protocols. Completion rate
of protocols per day was high in the BED and NC groups
(
92.5%) and fair in the BN group (77.5%). The BN
group produced a lower total number and less random

International Journal of Eating Disorders 40:6 521530 2007DOI 10.1002/eat

MAINTENANCE OF BINGE EATING THROUGH NEGATIVE MOOD

and eating protocols than the BED and NC groups, and

also showed longer reaction times (i.e., time in seconds
between beep sounds and acknowledgment keypresses;
all p < .05). Despite these group differences, the total
number of thought listing coding units did not differ
between groups (p > .05). Participants self-rated high
compliance for completion of protocols (4.73 6 0.95),
adequate representativeness of eating behavior during
the assessment period (4.33 6 1.54), and low to moderate
invasiveness of the EMA procedure (2.34 6 1.11; rating
scales of compliance, representativeness, and invasiveness ranged from 0 very low to 6 very high). Participants with BN reported signicantly greater invasiveness
than the NC participants (p < .05). Concerning physical
conditions with a potential inuence on mood and/or
appetite, groups did not differ on their menstrual cycles
or on intake of mood and/or appetite-affecting medication during the assessment period (both p < .05).

lytic step. Analyses were performed using the SPSS

MIXED procedure.

Data Analytic Plan

Preliminary Analysis: Patterns of Eating

The data analytic approach included parametric analyses for normally distributed variables and nonparametric
analyses in case of non-normal distributions (Kolmogorov-Smirnov goodness-of-t tests, p < .10). Data analysis of negative mood ratings was based on multilevel
random modeling in order to correspond to the repeated
and hierarchically nested structure of the data.17,38
Because of the unbalanced nature of the design, three
analytic models were selected to address Hypotheses 1 to
3. First, a two-level hierachical linear model of Eating
Disorder Group (BED, BN [between-subjects factor]) 3
Episode Type (binge eating, regular eating [within-subjects factor]) 3 Time (before, during, after [within-subjects factor]; subjects nested within event and time) was
used to analyze negative mood in the context of binge
eating and regular eating in BED and BN. Second, a twolevel hierachical linear model of Eating Disorder Group
(BED, BN [between-subjects factor]) 3 Assessment (prior
to binge eating, random [within-subjects factor]; subjects
nested within assessment) was used to compare mood
prior to binge eating and at random times in individuals
with BED and BN. Third, a two-level hierarchical linear
model of Group (BED, BN, NC [between-subjects factor])
3 Time (before, during, after [within-subjects factor];
subjects nested within time) was used to compare mood
in the context of binge eating in the eating disorder
groups and mood in the context of regular eating in the
NC group. In these models, the factors of group, episode
type, assessment, and time were treated as xed factors,
and subjects were treated as a random factor. In case of
signicant F ratios, Bonferroni tests were utilized for post
hoc analyses. To determine whether variations of negative mood in the hierarchical linear analyses were attributable to general psychopathology, the SCL-90-R-GSI
score was included as a covariate in an additional ana-

As presented in Table 3, participants overall

monitored more than four meals per day. The BED
group and the BN group indicated signicantly less
regular meals than the NC group (p < .05). Both
eating disorder groups reported about one binge
eating episode per day; 19 individuals with BED
(95.0% out of 20) and 16 individuals with BN
(80.0% out of 20) displayed at least one episode of
binge eating over the assessment period. Overall,
111 episodes of binge eating were reported by
87.5% of the eating disorder participants (35/40).
Fifteen participants with BN (75.0% out of 20)
reported at least one episode of inappropriate compensatory behavior over the assessment period,
whereas from the BED and NC groups, only one
participant each reported compensatory behavior
(1/20, 5.0%). The BN group reported a mean of 1.50
episodes of inappropriate compensatory behavior
per day (SD 2.15), mostly self-induced vomiting,
laxative, or diuretic misuse. While the duration of
episodes of regular eating did not differ between
groups (p > .05), the BED group reported a signicantly shorter duration of episodes of binge eating
than the BN group (p < .05). Overall energy intake
per day did not differ between groups (p > .05). The
BED and NC groups monitored a larger energy
intake from episodes of regular eating than the BN
group, whereas energy intake from binge eating
was lower in the BED group than in the BN group
(both p < .05).

For statistical analysis of negative cognitions of food/

eating, stress, and body image (Hypothesis 4), relative
frequencies were computed (number of cognitions divided by the number of thought listing protocols, i.e., random, regular eating, or binge eating protocols) because of
group differences in completion rates (see Control Variables). The nonparametric Mann-Whitney U test was used
for the analysis of group differences on cognitive contents
over the course of binge eating. As there were no effects of
assessment day on the dependent variables (p > .05), data
were collapsed across days. A two-tailed a level of 0.05
was applied to all statistical tests.

Results

Hypothesis 1: Negative Mood Is an Antecedent

of Binge Eating in BED and BN

Means and standard deviations for self-rated

mood are presented in Table 4. In both eating dis-

International Journal of Eating Disorders 40:6 521530 2007DOI 10.1002/eat

525

526

F(1, 33) 9.50*

Notes: M, mean; SD, standard deviation; F tests or KruskallWallis v2 tests.

a,b
Different superscripts indicate signicant group differences in univariate GLM and post hoc Bonferroni tests or MannWhitney U tests, p < .05.
*
p < .05.

343.508990.50
685.28
854.13

176.502901.50

2135.75

2612.92

F(2, 57) 2.93

F(2, 57) 15.05*
957.002643.00
957.002643.00
471.84
471.84
323.509112.50
122.001788.00
824.76
588.84
2402.50
1548.38a

941.504142.00
765.002997.50

3106.95
971.20b

2647.00
502.87

1867.28
1867.28a

F(2, 57) 0.34

F(1, 33) 7.96*
10.0031.00

6.95

5.0053.00
10.00179.00
10.74
8.60
18.98
12.66a

8.0057.00
5.0042.00

21.52
45.18b

11.61
49.51

19.74

v2(2, N 60) 31.01*

0.11
0.009.50
0.45
0.10a

0.002.00

1.50b

2.15

0.03a

0.030.11

F(2, 57) 1.98

F(2, 57) 9.79*
F(2, 57) 15.97*
2.008.50
2.008.50
0.000.00
1.71
1.71
0.00
4.95
4.95b
0.00b
0.5010.00
0.506.00
0.005.50
2.25
1.58
1.32
4.13
2.90a
1.23a
3.508.50
2.005.50
0.003.00
1.27
1.09
0.87

Range
SD
Range
SD
M

SD

Range

Bulimia
Nervosa (N 20)
Binge Eating
Disorder (N 20)

5.20
3.65a
1.55a

Total meals (n per day)

Total regular meals (n per day)
Total binge eating
episodes (n per day)
Total compensatory
behaviors (n per day)
Duration of regular meals (min)
Duration of binge
eating episodes (min)
Total energy intake (kcal per day)
Energy intake from regular meals
(kcal per day)
Energy intake from episodes of
binge eating (kcal per day)

TABLE 3.

Patterns of eating, binge eating episodes, compensatory behaviors, and energy intake

Non-Clinical
Control Group (N 20)

Test

HILBERT AND TUSCHEN-CAFFIER

order groups, mood was signicantly more negative prior to binge eating than regular eating, as
shown by a post hoc comparison of antecedent
negative mood by episode type (p .002), following a signicant interaction effect of Episode Type
3 Time (F(2, 174) 7.12, p .001). In both eating
disorder groups, mood prior to binge eating was
signicantly more negative than mood at random
assessment, as indicated by a signicant main
effect of assessment (F(1, 36) 7.62, p .009).
Further, mood prior to binge eating in the BED
and BN groups was signicantly more negative
than mood prior to regular eating in the NC group
(BED vs. NC: p .020; BN vs. NC: p < .001). These
post hoc tests were performed following a signicant Group 3 Time interaction effect (F(4, 104)
5.17, p .001). Including the SCL-90-R-GSI score
as a covariate modied the latter results: Only the
difference between the BN group and the NC
group remained signicant (p .031), whereas
the difference between the BED group and the NC
group failed to reach statistical signicance (p
.138). To summarize the results, negative mood
emerged as an antecedent of binge eating in both
BED and BN.

Hypothesis 2: Binge Eating in BED and BN Is

Associated with a Decrease of Negative Mood
Hypothesis 3: Binge Eating in BED Is
Associated with a Stronger Decrease of
Negative Mood than Binge Eating in BN

Concerning the mood course associated with

binge eating, negative mood increased after binge
eating compared with mood before and during
binge eating in both eating disorder groups (post
hoc tests, p  .008; see above Episode Type 3 Time
interaction, p .001). Mood was lower over the
course of binge eating than over the course of regular eating in both eating disorder groups, as
revealed by a signicant main effect of episode
type (F(1, 182) 72.30, p < .001). Regardless of episode type and time course, overall mood was more
negative in the BN group than in the BED group
(main effect of Eating Disorder Group: F(1, 37)
12.40, p .001). There were no signicant mood
changes over the course of regular eating in the NC
group (post hoc tests, p > .05; see the signicant
Group 3 Time interaction above, p .001). Including the SCL-90-R-GSI score as a covariate did not
modify these results. To summarize, there was no
indication that binge eating provided relief from
negative mood in the eating disorder groups, but
instead led to an increase in negative mood afterwards.

International Journal of Eating Disorders 40:6 521530 2007DOI 10.1002/eat

MAINTENANCE OF BINGE EATING THROUGH NEGATIVE MOOD

TABLE 4.

Negative mood at random assessment, regular eating, and binge eating

Binge Eating
Disorder (N 20)
Before

Non-Clinical
Control Group
(N 20)

Bulimia
Nervosa (N 20)

During

After

Before

During

After

Before

During

After

SD

SD

SD

SD

SD

SD

SD

SD

SD

3.95
3.80
3.25

1.13
0.75
0.93

4.08
3.58

0.58
1.09

4.15
2.67

0.69
1.07

3.18
3.49
2.75

0.81
0.90
1.10

3.61
2.88

0.92
1.38

3.19
1.59

1.14
1.41

4.31
4.12

0.83
0.85

4.22

0.85

4.31

0.99

Mood
Random
Regular eating
Binge eating

Notes: M, mean; SD, standard deviation; BED, binge eating disorder; BN, bulimia nervosa; NC, non-clinical control group.
a
Mood ratings, 0 very bad to 6 very good.

Hypothesis 4: Compared with Individuals with

BN, Individuals with BED Exhibit Less Negative
Food/Eating-Related and Less Stress-Related
Cognitions Over the Course of Binge Eating. In
Both Eating Disorders, Negative Cognitions
about Body Image Are Unrelated to Binge
Eating

FIGURE 1. Negative cognitions about food/eating, stress,

and body image at random assessment and over the
course of regular eating and binge eating. Mean frequencies of negative cognitions are presented, that is, number
of cognitions divided by the number of thought listing protocols (random, regular eating, or binge eating protocols).

The course of negative cognitions about food/

eating, stress, and body image at random assessment and in the context of regular eating and binge
eating is depicted in Figure 1. Nonparametric
Mann-Whitney U tests revealed more frequent negative food/eating-related cognitions (U 91.00, p
.042) and stress-related cognitions (U 84.00, p
.023) in the context of binge eating in the BN
group than in the BED group, but not in the context
of regular eating (p > .05). During binge eating, but
not before or after binge eating, the BN group
revealed more negative food/eating-related cognitions (U 92.00, p .034) and more negative
stress-related cognitions than the BED group (U
92.00, p .036). Negative body-related cognitions
were virtually nonexistent at random assessment,
regular eating, and binge eating.

Conclusion
The present investigation sought to examine negative mood as an antecedent and reinforcing condition of binge eating in BED and BN. A controlled
EMA design was used for random- and event-sampling of negative mood and cognitions in the naturalistic environment. Negative mood was conrmed as an antecedent of binge eating in both
BED and BN,1014 and was specically associated
with episodes of binge eating as compared with
regular episodes of eating or random assessment.
In contrast, our results did not support the notion
that binge eating provided relief from negative

mood in BED and BN: Binge eating in BED and BN

was not associated with or followed by a decrease
in negative mood, but by an increase in negative

International Journal of Eating Disorders 40:6 521530 2007DOI 10.1002/eat

527

HILBERT AND TUSCHEN-CAFFIER

mood. This course of negative mood was specic

for binge eating, as mood did not vary over the
course of regular eating. Relatedly, there was no indication that mood became more positive over the
course of binge eating. These results are consistent
with those from some previous EMA studies14,19
that documented an immediate deleterious effect
of binge eating on overall mood. Yet, they stand in
contrast to maintenance theories that would predict a reduction of negative mood through binge
eating.2,3,5
When interpreting these ndings, several methodological aspects deserve consideration: Concerning timeframe of assessment, the present study
focused on mood states immediately prior to, during, and after binge eating. Therefore, it cannot be
ruled out that a longer timeframe after binge eating
may have led to a decrease in negative mood. However, given the results by Wegner et al.,19 who did
not nd decreased post-binge mood when examining different timeframes on binge days of subclinical binge eaters, a delayed post-binge decrease of
negative mood is unlikely. An alternative explanation refers to this studys operationalization of
mood: The present study focused on overall negative mood proposed to be involved in the maintenance of binge eating,25 but it cannot be ruled out
that specic negative or positive emotional qualities would show a different course as suggested by
retrospective data on anxiety reduction,7 hedonics
of binge eating,9 and by EMA data on pleasantness.18 Further research using concurrent assessment of specic qualities of mood over the course
of binge eating would be desirable, simultaneously
considering other putative maintaining factors and
association with them, for example, restraint or low
self-concept,3,14,15,39 further clarifying the reinforcing potential of binge eating.
An intriguing nding is that antecedence through
negative mood in the BED group was in part attributable to general psychopathology,40 suggesting
that general psychopathology, including depressiveness and anxiety, predisposes individuals with
BED to more negative mood proximal to binge eating. Thus, general psychopathology contributed to
the maintenance of binge eating in this disorder
and may therefore be considered part of the eating
disorder symptomatology.23 In contrast, antecedence through negative mood was not modied by
general psychopathology in the BN group, possibly
because the BN group revealed more overall negative mood than the BED group, a result that is consistent with research from descriptive studies.4143
Consideration of the cognitive content related
to negative mood provided further information
528

about disorder-specic maintenance of BED

compared with that of BN. Consistent with previous research,7,9 concomitant experiences of binge
eating were less negative in BED than in BN.
Individuals with BED exhibited less negative cognitions on food/eating, presumably related to a
lesser sense of loss of control, and less stress,
possibly because of less physical discomfort from
binge eating. Negative body-related cognitions
were, as expected, not proximally related to binge
eating, and may therefore be considered more
distal maintaining factors of binge eating,14,44
likely in terms of negative cognitive schemata
about body image3 that do not necessarily surface unless activated by priming situations.32
Overall, these results underscore the relevance of
using ne-grained cognitive-emotional assessments when examining mood as a maintaining
factor of binge eating.
The results on eating patterns add to the few
existing comparative evidence in BED and BN.45
Caloric values of binge eating episodes in BED
were smaller than those in BN, as had been suggested by experimental studies using similar test
meal paradigms in samples with BED or BN.46
When evaluating energy intake, it is yet noted that
self-monitoring is subject to under- and overreporting biases, limiting reliability of ndings.47
Concerning self-denition of binge eating, eating
disorder participants, especially those with BED,
included subjective episodes of binge eating (i.e.,
consumption of a subjectively large amount of
food in a discrete period of time, accompanied by a
sense of loss of control over eating; see Table 3)40
when classifying eating episodes as binge eating, a
nding that is consistent with the literature.48,49 As
opposed to EMA studies that documented binge
eating episodes in overweight women without diagnosis of BED,1013 our non-clinical participants did
not report any episodes of binge eating, likely
because individuals with current or lifetime eating
disorders and symptoms of disordered eating were
excluded.
The results need to be interpreted with regard
to the strengths and limitations of the present
study. Strengths include an examination of both
antecedent and reinforcing conditions of binge
eating in BED and BN using mood ratings and
thought listing for assessment in a well-controlled
EMA study. Although the investigation was limited to two assessment days, the number of selfidentied binge eating episodes was considerable,
thereby providing an adequate empirical basis to
address the research questions. Compliance with
the EMA procedure was high and perceived inva-

International Journal of Eating Disorders 40:6 521530 2007DOI 10.1002/eat

MAINTENANCE OF BINGE EATING THROUGH NEGATIVE MOOD

siveness was low so that according to the participants view, a fairly representative picture of their
eating behavior was gathered. As with other community-based investigations, the participants
with BED and BN suffered from clinically signicant psychopathology that may in certain aspects
(e.g., shape concern) have been slightly less pronounced than in clinical samples.43,50 The major
limitation of the current study is the small sample
size that made minor mood uctuations and
group differences unlikely to be detected. Further,
because of the paper and pencil assessment of
psychological measures, time points of assessment of binge eating and/or purging could not be
fully controlled as would be possible with handheld computers that allow online recording of
these variables.17 Finally, it needs to be noted that
it remains unclear whether and how the different
methods of event- versus random-sampling
affected the mood ratings; the comparison of
mood prior to binge eating to mood at random
time points was used, among other comparisons
(see Methods section), for evaluating the specicity of negative mood as an antecedent condition
of binge eating.
For clinical implications, the results highlight the
relevance of detecting associations between binge
eating and mood because of potential antecedent
and reinforcing contingencies. The standard clinical tool for functional analysis of binge eating is
self-monitoring.47 Based on the results of the current study and on previous literature, it is recommended to explicitly assess the specic antecedent,
concomitant, and consequent emotions and cognitions in relation to food intake in order to examine
the conditions that maintain a patients dysfunctional eating patterns. Such an assessment is wellsuited to prepare for stimulus-control measures,
interventions to normalize eating patterns, cognitive restructuring, or awareness-based interventions, all of which are established in the treatment
of binge eating.41,42 Another implication of the current study is that, as the concomitant binge-related
experiences are less negative in BED than in BN,
the immediate deleterious effect of binge eating
may need to be more explicitly worked out in
patients with BED, for example, by outweighing
short- and long-term negative consequences of
binge eating.
Overall, the results show common and distinctive
features of BED and BN in the maintenance of
binge eating through negative mood. That binge
eating occurred under antecedent negative mood
but did not lead to a decrease of this mood suggests
that in both disorders binge eating likely results

from affect regulation difculties, but yet may not

be effective for affect regulation.

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