Appetite 71 (2013) 361–368

Contents lists available at ScienceDirect

Appetite
journal homepage: www.elsevier.com/locate/appet

Research report

Emotionally focused group therapy and dietary counseling in binge

eating disorder. Effect on eating disorder psychopathology and quality
of life q
Angelo Compare a,⇑, Simona Calugi b, Giulio Marchesini c, Edo Shonin d, Enzo Grossi e,
Enrico Molinari f, Riccardo Dalle Grave b
a
Human and Social Science Department, University of Bergamo, P.le S. Agostino, 2, 24129 Bergamo, Italy
b
Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, Italy
c
Unit of Metabolic Diseases & Clinical Dietetics, Alma Mater Studiorum University Bologna, Italy
d
Division of Psychology, Nottingham Trent University, Nottingham, UK
e
Bracco Foundation, Italy
f
Catholic University and Istituto Auxologico Italiano, Milan, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To test the effect on psychopathology and quality of life of Emotionally Focused Therapy (EFT),
Received 10 December 2012 Dietary Counseling (DC), and Combined Treatment (CT) in treatment-seeking patients with Binge Eating
Received in revised form 20 July 2013 Disorder (BED) and obesity. Methods: Utilizing an observational study design, 189 obese adult patients
Accepted 8 September 2013
with BED were treated by manualized therapy protocols. An independent assessment of health-related
Available online 21 September 2013
quality of life (Obesity-Related Well-Being questionnaire – ORWELL-97), attitudes toward eating (Eating
Inventory – EI), binge eating (Binge Eating Scale – BES) and body uneasiness (Body Uneasiness Test – BUT)
Keywords:
was performed at baseline, end-of-treatment, and six-month follow-up. These data are the secondary
Binge eating
Emotionally focused therapy
outcomes of a previously published treatment study. Results: A higher dropout rate was observed in
Obesity the DC compared to the EFT and CT groups, while body weight decreased significantly in all three groups.
Psychopathology Pre–post scores on the BES, BUT Global Severity Index, and EI Hunger subscale significantly decreased in
Binge eating attitude the CT and EFT groups (but not the DC group). At six-month follow-up, 71% of participants in CT and 46%
Body uneasiness of participants in EFT had a BES score below the threshold of attention for BED (616), whereas no partic-
ipants in the DC group reached this target. Finally the ORWELL-97 score decreased significantly in all
groups, but significantly more so in the CT and EFT groups. Conclusion: Results support the utility of com-
bining EFT and DC in the treatment of patients with BED and obesity, emphasizing the usefulness of tech-
niques focused on cognitive emotional processing for changing eating disorder psychopathology and
quality of life.
Ó 2013 Elsevier Ltd. All rights reserved.

Introduction as therapeutic options. Controlled studies have shown that these

Binge Eating Disorder (BED) is a complex and multifaceted eat-
ing disorder that requires a comprehensive treatment approach.
Multiple outcomes may be targeted in the treatment of obese indi-
viduals but BED remission and weight loss are mandatory. Antide-
pressant medications (Agras et al., 1994), cognitive-behavioral
therapy (CBT) (Latner et al., 2000; Wilson, Fairburn, Agras, Walsh,
& Kraemer, 2002), guided self-help based on CBT (Carter &
Fairburn, 1998), interpersonal psychotherapy (IPT) (Agras et al.,
1994; Wilfley et al., 2002), and behavioral weight loss treatment
(BWL) (Marcus, Wing, & Fairburn, 1995) have all been investigated
q
Conflict of interests: The authors declare there are no conflict of interests.
⇑ Corresponding author.
E-mail address: angelo.compare@unibg.it (A. Compare).
therapies are effective in reducing binge eating and associated
psychopathology in the short and long-term (Wilfley et al., 2002;
Wilson, Grilo, & Vitousek, 2007), but have a limited effect on body
weight. This finding was recently replicated in a study showing
that IPT, CBT, and guided self-help were all significantly more
effective than BWL in eliminating binge eating at 2 years, but not
in effectuating any long-term reductions in weight loss (Wilson,
Wilfley, Agras, & Bryson, 2010).
Recent research supports a model of binge eating that also in-
cludes emotional vulnerability and a deficit of skills that function-
ally modulate negative emotions, a mechanism not directly
addressed by either CBT or IPT. For example, data suggest that dif-
ficulties in emotion regulation (Whiteside et al., 2007) and emo-
tional eating (Ricca et al., 2009) are strongly associated with
binge eating, independently of sex, food restriction, and/or

0195-6663/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.appet.2013.09.007
362 A. Compare et al. / Appetite 71 (2013) 361–368

over-evaluation of weight and shape. Other findings show that of participants with P5% weight loss at the end of treatment and at
binge eating may be triggered by an immediate break-down of six-month follow-up. In the planning of the study, we considered
emotion regulation (Munsch, Meyer, Quartier, & Wilhelm, 2011; that the limited utilization of EFT in empirical studies was difficult
Whiteside et al., 2007). Two randomized controlled trials (Safer, to reconcile with a properly randomized trial. In particular, it was
Robinson, & Jo, 2010; Telch, Agras, & Linehan, 2001) with dialecti- difficult to make a reliable estimate of the dropout rate. Thus, in
cal behavior therapy adapted for BED (DBT-BED) (Wiser & Telch, conjunction with our previous experience with propensity score
1999) showed that DBT-BED (a treatment specifically addressing adjustment, a non-randomized design was employed.
events and mood changes associated with binge eating) was more In a previous study, we showed that EFT and CT were both
effective than a wait-list control in eliminating binge eating. How- highly effective in improving the desirable targets compared with
ever, therapeutic gains were not maintained at 12-month follow- DC in the short-term and at six-month follow-up (Compare, Calugi,
up, indicating the absence of any specific effect of the experimental Marchesini, Molinari, & Dalle Grave, 2013). The current study re-
treatment on long-term outcomes. An enhanced form of CBT for ports on secondary outcomes that relate to eating disorder and
eating disorder (CBT-E) introduced a DBT-derived mood intoler- body image-related psychopathology and quality of life.
ance module for addressing eating-inducing events and associated
mood changes, but its efficacy has not been empirically assessed in
individuals with BED (Fairburn, Cooper, & Shafran, 2003). Materials and methods
Emotionally Focused Therapy (EFT) is a promising intervention
for binge eating. Unlike DBT-BED, which encourages patients to ob- Participants
serve and describe their emotions in a nonjudgmental way, EFT fo-
cuses more on the cognitive and interpersonal experiential The general flow of participants through the study is summa-
perspective. Within the EFT framework, once recognition of the rized in Fig. 1 and has been presented in a previous report (Com-
emotional experience occurs, clients must cognitively orient to pare et al., 2013). The study involved adult patients (n = 189)
that experience as a source of information in order to explore, re- meeting DSM-IV research criteria for BED (American Psychiatric
flect on, and make sense of it. This is achieved by examining the be- Association, 1994) who were referred to our outpatient depart-
liefs associated with the experienced emotion, and by identifying ment for the treatment of eating disorders by family doctors or
factors that can motivate a change in personal meanings and be- other clinicians. To be eligible for the study, patients were required
liefs. EFT recognizes the adaptive function of emotion as well as to: (i) be aged between 35 and 60 years, (ii) have a body mass in-
the potential for learning and formation of new neural organiza- dex (BMI) of 30 or greater, and (iii) meet DSM-IV criteria for BED.
tions known as ‘‘emotion schemes’’. Such schemes are automatic Exclusion criteria were: (i) concurrent treatment for eating, weight,
and invariably occur ‘out-of-awareness’, yet hold a tremendous or psychiatric illness, (ii) active medical condition that might have
influence over an individual’s emotional processing (Greenberg, influenced weight or eating (e.g., diabetes or thyroid problems – as
2011). A recent review of empirically supported psychological determined by laboratory testing), (iii) severe current psychiatric
therapies for mood disorders in adults showed promising results conditions requiring different treatments (e.g., psychosis, bipolar
for EFT (Hollon & Ponniah, 2010). These results related to both disorder), and (iv) pregnancy or lactation. Following receipt of
acute response and subsequent prevention of depressive symp- written informed consent, patients meeting all of the eligibility
toms (Ellison, Greenberg, Goldman, & Angus, 2009; Watson, Gor-
don, Stermac, Kalogerakos, & Steckley, 2003). However, to date,
research examining EFT in a group setting has been limited to a
small number of studies (e.g., Pascual-Leone, Bierman, Arnold, &
Stasiak, 2011).
The limited effect on body weight of available treatments
prompted us to devise new approaches for the management of
BED-associated obesity. A potentially useful strategy might be
the combination of psychotherapy for BED with dietary Counseling
(DC) for weight loss, based on a reduction of energy dense foods.
The rationale for this hypothesis comes from the observation that
obese individuals with BED have increased gastric capacity com-
pared to those without BED (Geliebter & Hashim, 2001). Further-
more, a lower consumption of energy-dense meals has been
shown to reduce energy intake in individuals with BED (Latner,
Rosewall, & Chisholm, 2008). This combined interventional ap-
proach has recently been tested in obese patients with BED where
DC for weight loss was administered in conjunction with CBT for
binge eating, and compared against CBT with integrated general
nutrition counseling (Masheb, Grilo, & Rolls, 2011). The two treat-
ments did not produce any differences in weight loss or binge
remission. However, based on dietary outcomes of energy-dense
food, and fruit and vegetable consumption, patients allocated to
CBT plus DC responded better than those allocated to CBT plus gen-
eral counseling. Thus, low-energy–density dietary counseling
might be an effective method for enhancing the effect of psycho-
therapy for obese individuals with BED.
Utilizing an observational design, the purpose of the current
study was to assess the effects of DC, EFT, and Combined Treatment
(CT) in treatment-seeking patients with BED and obesity. Primary
outcomes were: (a) remission from binge eating and (b) proportion Fig. 1. Flow diagram of the study.
 A. Compare et al. / Appetite 71 (2013) 361–368
criteria completed baseline assessment procedures and entered
one of two treatment programs (described below). Group alloca-
tion was based on various criteria (also described below) including
psychometric test-informed therapist judgment and personal
acceptance.
Diagnostic assessment
The diagnostic assessment was completed by experienced clin-
ical psychologists. The DSM-IV diagnosis of BED was based on the
Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P
[First, Spitzer, Gibbon, & Williams, 1996]) which has excellent in-
ter-rater reliability (kappa = 1.0) for BED.
Outcome measures
The effects of treatment on eating disorder-related psychopa-
thology and quality of life were tested per protocol using the fol-
lowing questionnaires:
Binge eating scale
(BES [Gormally, Black, Daston, & Rardin, 1982]): The BES is a
16-item self-report measure of the presence and severity of behav-
ioral and cognitive characteristics of binge eating. Individual items
(graded from 0 to 3) examine both behavioral signs (e.g., eating
large amounts of food) and feeling or cognition during a binge epi-
sode (e.g., loss of control, guilt, fear of being unable to stop eating).
The sum of responses (i.e., the total BES score) provides a continu-
ous measure of binge eating pathology from 0 to 48. A score P 27
conventionally serves as a cutoff value for identifying the presence
of a severe eating disorder such as BED. Scores of 616 may be used
as screening values to exclude binge eating (Greeno, Marcus, &
Wing, 1995). The BES is widely utilized in research on BED (Gladis,
Wadden, Foster, Vogt, & Wingate, 1998) and has excellent internal
consistency (Cronbach’s alpha: from 0.85 to 0.89) (Freitas, Lopes,
Appolinario, & Coutinho, 2006; Gormally et al., 1982).
Body uneasiness test
(BUT [Cuzzolaro, Vetrone, Marano, & Garfinkel, 2006]). The BUT
examines body shape and/or weight dissatisfaction, avoidance,
compulsive control behaviors, feelings of detachment and
estrangement toward one’s own body, and specific worries about
particular body parts, shapes, or functions. The BUT consists of
34 items with scores ranging from 0 (never) to 5 (always). Scores
are summed to form a Global Severity Index and higher scores indi-
cate greater levels of body uneasiness (the BUT also comprises five
subscales but these were not utilized in the present study). Test–
retest correlation coefficients are highly significant (BUT-Global
Severity Index, 0.89) and Cronbach’s alpha coefficients indicate
good internal consistency (range, 0.64–0.89) (Cuzzolaro et al.,
2006; Marano et al., 2007). Exploratory and confirmatory analyses
has found the same structural model in normal-weight individuals,
in subjects without eating disorders (Cuzzolaro et al., 2006), and in
patients with obesity (Marano et al., 2007).
Eating inventory
(EI [Stunkard & Messick, 1988]) (previously known as the Three-
Factor Eating Questionnaire [Stunkard & Messick, 1985]): The EI is a
51-item self-report measure of eating attitudes with response
scores on either a four-point (1 = rarely, 2 = sometimes, 3 = usually,
4 = always) or five-point Likert scale. Scores range from 1 (eat
whatever and whenever you want) to 5 (constantly limiting food
intake, never ‘giving in’) and are arranged into three domains: (i)
363
dietary Restraint (the cognitive ability to restrain food intake),
(ii) disinhibition (tendency to lose control over eating), and (iii)
hunger (the perception of hunger/satiety). Higher scores indicate
greater levels of restraint, disinhibition, and hunger. The Cron-
bach’s alpha coefficients of the three domains (range, 0.85–0.93)
reflect a good level of internal consistency (Cappelleri et al.,
2009; Karlsson, Persson, Sjostrom, & Sullivan, 2000; Stunkard &
Messick, 1985). The scale exhibits good reliability and validity that
has been established in numerous studies (e.g., Gorman & Allison,
1995).
Obesity-related well-being
(ORWELL-97 [Mannucci et al., 1999]). The ORWELL-97 is an 18-
item questionnaire measuring obesity-related quality of life
(Mannucci et al., 1999). For each item of the scale, patients are
asked to score the intensity of the symptoms and the subjective
relevance of these symptoms to their own lives. Scoring is based
on a 4-point Likert scale and the final score reflects the intensity
and subjective relevance of physical and psychological distress
generated by overweight. Higher scores indicate higher levels of
distress. The ORWELL-97 has been widely used in research involv-
ing obese individuals (e.g., Allegri, Russo, Roggi, & Cena, 2008;
Mannucci et al., 2010; Minniti et al., 2007; Petroni et al., 2007),
and has good levels of internal consistency (Cronbach’s alpha total
score, 0.83) (Mannucci et al., 1999).
Treatment
Emotionally focused group therapy
EFT was administered as 20 group sessions (10–15 participants
per group; weekly sessions of 60–90 min duration) over a five-
month period. EFT adapted for BED is a focal treatment consisting
of three overlapping phases (Greenberg, 2002). During the first
phase, the therapist helps clients to: (i) reflect on and reevaluate
emotion schemes linked with binge eating, (ii) describe their feel-
ings in words in order to aid them in solving problems, and (iii) be-
come aware of whether their emotional reactions are their primary
feelings in this situation. During the second phase, therapists help
clients to explore secondary reactive and primary maladaptive
emotional responses. In the final phase, the client is helped to ac-
cess subdominant adaptive emotional responses. In the current
study, group sessions comprised: (i) a review of the past week
and participant updates, (ii) one-to-one participant chair-work ses-
sion1 (approximately 45 min duration), with a second therapist
monitoring the group for reactions, (iii) analyses of the participant’s
chair-work, and (iv) weekly end-of-session questionnaires. Accord-
ing to the manual guidelines (Elliott & Greenberg, 2007), the specific
goals of EFT are: (a) the identification of interpersonal needs, past
and current patterns of interpersonal behavior that attempt to sat-
isfy those needs, and the corresponding underlying emotional expe-
riences, (b) the development of effective interpersonal behavior to
satisfy such needs in a more adaptive manner; and (c) the identifica-
tion and processing of avoided emotions associated with all thera-
peutic engagement. Specific EFT techniques utilized in the group
sessions included the ‘two-chair dialogue’, the ‘empty-chair
dialogue’, and the ‘two-chair enactment’ for a self-interruptive split
(wherein one part of the client’s self interrupts or constricts
1
In this technique, the therapist uses an empty chair to help the client become
more aware of their feelings and to develop a stronger ability to cope with daily living
situations. This technique is based on three variations: (a) patients express one side of
the conflict in each chair, and switch chairs as the conversation progresses, (b)
patients express their feelings in one chair, then switch chairs and express the
significant other’s imagined response, and (c) patients sit in one chair and speak to an
imagined significant other in the empty chair, with no imagined response from the
significant other.
364 A. Compare et al. / Appetite 71 (2013) 361–368
emotional experience and expression) (Greenberg, 2011; Robinson,
McCague, & Whissell, 2012). EFT proposes that helping clients
change the way in which they access and use their emotions in an
empathic and caring relationship leads to the modification of their
emotion schemes as well as the self-organizational frameworks
responsible for problematic psychological functioning (Elliott &
Greenberg, 2007). Thus, according to the EFT framework, negative
symptoms reflect the operation of implicit over-generalized emotion
schemes developed through personal experience.
Dietary counseling
DC was administered as 12 one-hour weekly individual sessions
during the first three-months of treatment, followed by eight
weekly group sessions (30 min duration). During the last two
months of treatment, DC was based on dietary counseling targeting
the reduction of energy-dense food intake (Dalvit-McPhillips,
1984). During the first (i.e., the one-to-one) treatment phase, ther-
apeutic themes included (i) obesity and its causes, (ii) evaluation of
nutritional status, (iii) correct nutritional choices (e.g., alimentary
pyramid, energy and nutritional requirements), and (iv) desirable
body weight. During the second (i.e., the group) treatment phase,
patients received instruction on (i) the preparation of meals with
different energy density, (ii) the calculation of energy density using
nutrition facts labels, and (iii) utilizing the energy–density formula
and an energy–density value food chart. Patients were also in-
formed about biological and social stimuli that regulate food intake
and on strategies for practicing regular physical activity and for
long term weight management. Clinicians reviewed the weekly
topics and helped patients overcome obstacles preventing them
from achieving energy density intake goals. Information was also
provided on sample meals, menus, and recipes.
Combined treatment
In half of the participants in the EFT group, sessions were com-
bined with DC. During the first three months of treatment, the DC
sessions for participants receiving CT were programmed to take
place on the same day (and one hour before) the EFT sessions. Dur-
ing the final two months of treatment, sessions were conducted on
a group basis and comprised 60 min devoted to EFT and 30 min de-
voted to DC. Participants completed daily food diaries that were
checked weekly by clinicians. Participants were also instructed to
self-monitor and report episodes of binge eating and overeating.
Treatment assignment
Treatment condition assignment was conducted by an experi-
enced clinical psychologist and was based on psychometric test re-
sults, clinical interview, and partly on patients’ preferences. EFT
was preferred whenever binge eating was considered to be emo-
tional in origin, whereas DC was preferred in subjects who re-
quired intense nutritional counseling. CT was favored where
clinicians deemed that patients with emotion-derived binge eating
would benefit from comprehensive nutritional counseling. How-
ever, other factors were also considered including: (i) time on
the waiting list, (ii) participants being unable to attend at certain
times of day, and (iii) the need to keep group sizes in each alloca-
tion condition (i.e., EFT, DC, and CT) as equal as possible.
Six-month follow-up period
No treatment was provided during the six-month follow-up
period (i.e., after the end of the 20 week treatment phase). How-
ever, throughout the follow-up period, participants were encour-
aged to practice and apply the principles and techniques of the
EFT and/or DC. Where possible, participants were encouraged to
refrain from additional treatments or drug use before the six-
month follow-up assessment but were provided with access to
the study investigators for assistance with treatment planning or
referrals.
Sample size calculation
The sample size was calculated on the primary outcome of BED
remission. Based on a review and analysis of the literature, we
hypothesized binge eating remission (DSM-IV diagnosis [First
et al., 1996]) in 30% of participants at follow-up, and twice as many
in at least one of the experimental arms. The total number of par-
ticipants, allowing for a type 1 error of 0.05, a type 2 error of 0.10,
and multiple comparisons summed up to 58 participants per
group. The number was increased by 10% to account for attrition.
Statistical analysis
Statistical analysis was carried out on data for completers, com-
paring the effects of treatments on outcomes. Comparisons were
performed using a propensity score approach in order to adjust
treatment outcomes for baseline values. Utilizing logistic regres-
sion analysis, the propensity score was calculated as the probabil-
ity to be assigned to a structured program (EFT with/without DC)
based on clinical variables at baseline. The propensity score in-
cludes the conditional probability to be assigned to any specific
treatment given individual characteristics, as well as the probabil-
ity to accept the proposal suggested by physicians. The variables
included in the logistic regression to calculate the score were
age, sex, education, civil status, BMI, and BES value at baseline.
Propensity scores were then used to adjust for baseline values
in logistic regression analysis in different models, whereby treat-
ment group was set as independent variable. DC was considered
as the reference treatment. EFT with/without DC were also com-
pared with each other (using EFT as the reference). Repeated-mea-
sures analysis of variance controlling for propensity score was
performed in order to test significant changes from baseline to
six-month follow-up in the three groups. In order to determine
the possible confounding effects of binge remission on BUT and
quality of life, the analyses was repeated after further adjustment
for BES changes from baseline to six-month follow-up.
Finally, linear regression analysis was carried out to test signif-
icant associations between outcome measures.
Results
Table 1 shows participants’ demographic and clinical character-
istics. At baseline, sex, marital status, and educational level were
significantly different among the three groups. Higher rates of
males and lower educational level were found in EFT compared
with both the CT and DC groups. A lower percentage of patients
were reported living with a partner in the DC group. The DC group
was characterized by lower BMI compared with the CT group, and
by higher scores on the ORWELL-97 compared with both the CT
and EFT groups. Finally, the EFT group had higher ORWELL-97
scores than CT group. All participants had severe BED (as con-
firmed by high scores on the BES).
Attrition
Although most participants missed a few sessions (EFT: median
missed sessions = 1.3, min = 1, max = 3; DT: median = 1.5, min = 1,
max = 3; CT: median = 1.4, min = 1, max = 3), dropout was defined
by a complete discontinuation of attendance and failure to present
at follow-up appointments. A total of 164 patients (86.8%) com-
pleted the treatment (continuers), whereas 25 patients (13.2%) left
the program before conclusion (dropouts). A higher rate of dropout
 A. Compare et al. / Appetite 71 (2013) 361–368 365

Table 1
Baseline psychometric testing in the three groups. Data are presented as mean ± SD, as §median [interquartile rage] or as number of cases (%).

EFT group (N = 63) CT group (N = 63) DC group (N = 63) Test° p Value

Sex, N (%)
Males 21 (33.3%) 37 (58.7%) 37 (58.7%) 10.84 0.004
Female 42 (66.7%) 26 (41.3%) 26 (41.3%)
Marital status, N (%)
Single 17 (27.0%) 13 (20.6%) 13 (20.6%) 9.14 0.058
Living with partner 44 (69.8%) 49 (77.8%) 42 (66.7%)
Widowed 2 (3.2%) 1 (1.6%) 8 (12.7%)
Educational level, N (%)
Elementary school 17 (27.0%) 8 (12.7%) 17 (27.0%)
Junior high school 30 (47.6%) 22 (34.9%) 24 (38.1%)
Senior high school 14 (22.2%) 24 (38.1%) 22 (34.9%) 20.23 0.010
Degree 1 (1.8%) 5 (7.9%) 0
Other 1 (1.8%) 4 (6.3%) 0
Current BMI (kg/m2) 33.0 ± 1.6 33.6 ± 2.6 32.3 ± 1.3a 7.32 0.001
Age (years) 50.8 ± 6.0 51.1 ± 4.1 50.4 ± 4.7 0.31 0.733
Objective bulimic episodes§ 17.5 [4.5] 17.5 [1.8] 16.9 [5.2] 0.34 0.845
Binge Eating Scale 34.2 ± 4.2 33.8 ± 4.6 32.9 ± 3.9 1.48 0.231
a a,b
ORWELL-97 79.4 ± 3.6 76.4 ± 3.1 84.5 ± 6.5 43.13 <0.001
BUT-GSI§ 3.2 ± 1.3 3.3 ± 1.2 3.6 ± 1.3 1.42 0.243
Three Factor Eating Questionnaire
Dietary restraint 10.5 ± 2.8 9.6 ± 1.8 11.1 ± 2.7b 6.04 0.003
Disinhibition 13.9 ± 1.2 13.8 ± 1.2 13.6 ± 1.6 0.65 0.523
Hunger 12.7 ± 0.7 12.9 ± 0.2 12.6 ± 0.9 2.84 0.061
°
ANOVA with post hoc Bonferroni or Kruskall–Wallis with Bonferroni correction (p < 0.016) or Chi-Square test, as necessary.
a
p < 0.016 vs. EFT group.
b
p < 0.016 vs. CT group.

was reported in the DC group compared with the EFT and CT
groups (27% vs. 12.7% vs. 0%, respectively; X2 (2, N = 189) = 20.01,
p < 0.001). A post hoc analysis showed that there were no signifi-
cant differences in sex, age, and baseline BMI between participants
who attended the follow-up assessment (164 of the 189 patients
enrolled) and dropouts.
Body weight
group reaching this target. EI-Restraint increased significantly in
the three groups from baseline to end of therapy, but these thera-
peutic gains were only maintained through to six-month follow-up
by the DC group. EI-Disinhibition decreased significantly in the
three groups (Table 2). After adjustment for changes in BES score,
differences were no longer observed, indicating that changes on
body image dissatisfaction were largely dependent on binge eating
remission.

The average body weight at baseline was 99.1 ± 6.8 kg (BMI,
32.3 ± 1.3 kg/m2) for the DC group, 99.9 ± 8.5 (BMI, 33.0 ± 1.6) for
the EFT group, and 97.9 ± 5.2 (BMI, 33.6 ± 2.6) for the CT group.
At the end of the treatment, body weight had decreased to
93.0 ± 0.5 (BMI, 30.3 ± 2.4) for the DC group, 90.0 ± 0.5 (BMI,
30.1 ± 2.1) for the EFT group, and 89.5 ± 3.2 (BMI, 30.3 ± 1.9) for
the CT group (all groups, p < 0.001). At six-month follow-up, the
average body weight was 93.7 ± 2.4 (BMI, 30.5 ± 2.6) for the DC
group, 86.7 ± 0.6 (BMI, 29.3 ± 1.7) for the EFT group, and
86.9 ± 0.5 (BMI, 29.2 ± 1.8) for the CT group (p = 0.035, p < 0.001,
and p < 0.001 respectively). The overall percentage change in body
weight averaged 11.4 ± 5.4% for EFT group, 13.2 ± 8.6% for the
CT group, and 5.4 ± 7.7% for DC group (all groups, p < 0.001).
Health-related quality of life
After controlling for propensity score, pre–post scores on the
ORWELL-97 decreased significantly in all groups, but more so in
CT and EFT groups compared to the DC group (Table 2). More spe-
cifically, scores decreased by 22.7 ± 5.0 points for the EFT group, by
21.8 ± 3.4 points for the CT group, and by just 12.6 ± 7.4 points for
the DC group (all groups, p < 0.001). Of particular note, changes in
ORWELL-97 scores at follow-up were not only associated with
changes with body weight (r = 0.296; p < 0.001), but to a greater
extent were also associated with changes in BES scores
(r = 0.695; p < 0.001) (Fig. 2). A repeated analysis controlled for
changes in BES scores and confirmed the significant decrease in
ORWELL-97 scores for all groups.

Eating disorder-related psychopathology

Repeated analysis of variance, controlling for propensity score,
indicated that pre–post scores on the BES, BUT-GSI and EI-Hunger
had significantly decreased in the CT and EFT groups (but not the
DC group). By the end of treatment, 63% of CT participants and
33% of EFT participants had a BES score that was below the thresh-
old of attention for BED (616), whereas no participants in the DC
group reached this target. At six-month follow-up, the same
threshold was attained by 71% and 46% of participants in CT and
EFT groups respectively – again with no participants in the DC
Discussion
This is the first study assessing the relative effectiveness of EFT,
DC, and CT in treatment-seeking patients with BED and obesity. In
the current study, the positive effects of EFT and CT on primary tar-
gets (Compare et al., 2013) were extended to secondary outcomes.
Participants in both the CT and EFT groups demonstrated signifi-
cantly better outcomes at therapy termination and follow-up than
participants in the DT group. These outcomes related not only to
reductions in weight, but also to improvements in psychopathology
366 A. Compare et al. / Appetite 71 (2013) 361–368

Table 2
Psychosocial measures at baseline, at the end of therapy and after six-month follow-up. Data are presented as mean ± SD.

EFT group (N = 55) CT group (N = 63) DC group (N = 46) Repeated measures#

ANOVA (df = 2160)
Baseline End of Six-month Baseline End of Six-month Baseline End of Six-month Time X Group
therapy follow-up therapy follow-up therapy follow-up
Binge Eating Scale 34.0 ± 4.4 17.0 ± 2.9 16.0 ± 2.4 33.8 ± 4.6 15.1 ± 1.9a 15.5 ± 1.0 33.6 ± 4.5 32.3 ± 1.6a,b 32.3 ± 3.6a,b 197.0*
Body Uneasiness Test-GSI§ 3.2 ± 1.3 2.1 ± 0.6 2.2 ± 1.0 3.3 ± 1.2 2.0 ± 0.7 2.2 ± 0.7 3.6 ± 1.3 3.8 ± 0.5a,b 3.9 ± 0.5a,b 12.9*
Eating inventory
Dietary restraint 9.8 ± 1.9 13.3 ± 2.8 9.1 ± 2.3 9.6 ± 1.8 12.2 ± 0.3a 6.3 ± 0.9a 9.9 ± 1.5 18.2 ± 1.9a,b 15.9 ± 1.3a,b 194.8*
Disinhibition 13.9 ± 1.1 8.0 ± 2.7 11.0 ± 2.2 13.8 ± 1.2 5.2 ± 0.3a 12.2 ± 0.3a 13.8 ± 1.3 13.9 ± 11a,b 10.5 ± 1.3b 12.8*
Hunger 12.9 ± 0.2 7.0 ± 2.2 6.8 ± 1.2 12.9 ± 0.2 7.2 ± 0.3 7.0 ± 1.0 12.9 ± 0.2 11.5 ± 1.2a,b 11.6 ± 0.4a,b 112.4*
ORWELL-97 79.4 ± 3.6 56.0 ± 7.3 56.7 ± 3.4 76.4 ± 3.1 55.3 ± 1.8 54.1 ± 2.0a 84.5 ± 6.5 70.7 ± 4.2a,b 71.9 ± 1.7a,b 27.3*
#
After controlling for propensity score.
*
p < 0.001.
a
p < 0.016 vs. EFT group.
b
p < 0.016 vs. CT group at the same time point.
§
Global Severity Index.

Fig. 2. Regression plot of changes between baseline and f6-month follow-up
changes in ORWELL-97 and body weight (upper panel) or BES score (lower panel) in
the three groups.
and quality of life. Of particular noteworthiness, CT resulted in the
greatest improvements in binge eating and weight loss that
were maintained through to six months following the end of
treatment.
Clinically, our results, along with data from other groups (Chen,
Matthews, Allen, Kuo, & Linehan, 2008; Clyne, Latner, Gleaves, &
Blampied, 2010; Telch et al., 2001), stress the utility of structured
therapeutic techniques focused on emotions to interrupt the dys-
functional pattern of emotional dependence on food in BED patients.
The data also suggest that the combination of psychotherapy and DC
might be a promising strategy to produce both an improvement of
the eating disorder psychopathology and a healthy weight loss. A
technique such as EFT that specifically focuses on emotional experi-
ence might help to break the vicious cycle that exists between faulty
cognitive-emotional processing and maladaptive eating behavior.
This manner of targeting the dysfunctional emotions that underlie
BED is likely to augment the effectiveness of methods such as DC.
EFT with/without DC produced a reduction of mean BES scores
of approximately 50% and this improvement was maintained at
six-month follow-up in both experimental groups. The majority
of participants in the EFT and CT groups had BES scores 6 16, i.e.,
within the cut-off of normal values (Gormally, Black, Daston, &
Rardin, 1982). In addition, both EFT and CT produced a significant
improvement in body uneasiness by the end of treatment, which
was also maintained at follow-up. These data confirm previous
observations on the relationship between changes in body image
and binge eating (Dalle Grave et al., 2007). Finally, the three inter-
ventions decreased Disinhibition and increased Dietary Restraint
by the end of treatment while only CT and EFT reduced Hunger.
This effectively mimics changes in BES scores. While an increase
in cognitive restraint has been associated with weight loss in obese
patients seeking treatment at medical centers (Dalle Grave, Calugi,
Corica, Di Domizio, & Marchesini, 2009), increasing restraint might
be associated with negative long term effects on the severity of
eating disorder (Blomquist & Grilo, 2011). A greater length fol-
low-up period than that employed in the current study would be
required to explore this hypothesis further.
Binge eating is an important component of the poor quality of
life associated with obesity. In a large population with obesity, a
BES score above the selected cut-offs was associated with poor
quality of life across a range of somatic and psychological domains
(Mannucci et al., 2010). In the present study, there were no differ-
ences between groups in weight loss at the end of treatment, and
reductions in weight were only moderately larger in the CT and
EFT groups compared to DC group at follow-up. Nonetheless,
changes in the ORWELL-97 scores were highly significant and
much larger for the CT and EFT groups vs. the DC group. The signif-
icant correlation observed between the changes in BES and OR-
WELL-97 scores at follow-up, which was greater than the
correlation between changes in ORWELL-97 scores and body
weight, supports a role of binge eating remission as a possible dri-
ver of improved quality of life.
In general, our results indicate that improved processing of mal-
adaptive emotional schemes helps to ameliorate the need to use
food to modify emotional experience. The possible mechanisms
of action of the EFT treatment may be attributed to the process-
experiential therapeutic approach of the group setting. By allowing
the patient to experience ‘‘live’’ the relational dimensional of emo-
tions, and by increasing social support via improved interpersonal
relationships, patients may benefit from long-lasting improve-
ments in emotional regulation as well as associated reductions in
weight and binge eating episodes. The analysis of dropouts indi-
cated that participants experienced EFT as a more acceptable op-
tion than DC and this is an additional factor which explains why
patients in treatment arms utilizing EFT responded more favorably.
Previously-reported DBT-BED trials (Safer et al., 2010; Wiser &
Telch, 1999) demonstrated that positive outcomes were not
 A. Compare et al. / Appetite 71 (2013) 361–368
maintained at 12-month follow-up. Although it is not possible to
make direct comparisons, findings from the follow-up component
of the present study suggest that the different approach to emo-
tional experience employed by EFT might result in long-lasting
benefits. However, further empirical investigation is required to
evaluate this hypothesis.
The present study has two main strengths. First, it is the first re-
port on the effect of EFT, either alone or combined with DC, in the
treatment of patients with BED and obesity. Second, its observa-
tional design and the several questionnaires filled in by patients al-
lowed for a comprehensive analysis of the effects of different
treatments on a variety of outcomes – including eating disorder-
related and quality of life-associated parameters in a ‘‘real world’’
obesity center setting.
The study is also limited by a number of factors. First, despite a
post hoc analysis showing that the group available at follow-up
was not different from the total entry population, the subjects in
the DC group had higher rates of dropout compared to those in
both EFT and CT groups. Second, the analyses were based on a pro-
pensity score approach. The propensity method adjusts the effect
of treatment for multiple known confounders, but it cannot control
for residual unknown variables. Furthermore, the propensity score
approach does not overcome a possible initial selection bias (Fos-
ter, 2003; Little & Rubin, 2000). Thus, this study’s findings are def-
initely less robust than those obtained by randomized controlled
trials (Rubin, 2007), but adjusting by propensity produces valuable
data reflecting the ‘‘real world’’ of disease treatment and the proce-
dure is largely accepted in the study of chronic diseases. This is a
limitation from the point of view of evidence-based medicine,
but it is a point of strength in terms of external validity, provided
that new data emerges to confirm the positive outcomes obtained
with CT and EFT at longer follow-up.
In conclusion, despite the abovementioned limitations, our re-
sults reinforce the potential usefulness of EFT for the treatment
of binge eating. Techniques focused on cognitive and interpersonal
experiential perspective of the emotions, particularly when associ-
ated with DC produce positive results on binge-eating remission,
weight loss, eating attitudes toward eating, body uneasiness, and
health related quality of life in treatment-seeking BED patients
with obesity.
References
Agras, W. S., Rossiter, E. M., Arnow, B., Telch, C. F., Raeburn, S. D., Bruce, B., & Koran,
L. M. (1994). One-year follow-up of psychosocial and pharmacologic treatments
for bulimia nervosa. Journal of Clinical Psychiatry, 55, 179–183.
Allegri, C., Russo, E., Roggi, C., & Cena, H. (2008). Quality of life (QoL) and motivation
for treatment. A female issue? Eating and Weight Disorders, 13, e8–e13.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental
disorders (4th ed.). Washington, DC: American Psychiatric Association.
Blomquist, K. K., & Grilo, C. M. (2011). Predictive significance of changes in dietary
restraint in obese patients with binge eating disorder during treatment.
International Journal of Eating Disorders, 44, 515–523.
Cappelleri, J. C., Bushmakin, A. G., Gerber, R. A., Leidy, N. K., Sexton, C. C., Lowe, M. R.,
& Karlsson, J. (2009). Psychometric analysis of the Three-Factor Eating
Questionnaire-R21. Results from a large diverse sample of obese and non-
obese participants. International Journal of Obesity (Lond), 33, 611–620.
Carter, J. C., & Fairburn, C. G. (1998). Cognitive-behavioral self-help for binge eating
disorder. A controlled effectiveness study. Journal of Consulting and Clinical
Psychology, 66, 616–623.
Chen, E. Y., Matthews, L., Allen, C., Kuo, J. R., & Linehan, M. M. (2008). Dialectical
behavior therapy for clients with binge-eating disorder or bulimia nervosa and
borderline personality disorder. International Journal of Eating Disorders, 41,
505–512.
Clyne, C., Latner, J. D., Gleaves, D. H., & Blampied, N. M. (2010). Treatment of
emotional dysregulation in full syndrome and subthreshold binge eating
disorder. Eating Disorders, 18, 408–424.
Compare, A., Calugi, S., Marchesini, G., Molinari, E., & Dalle Grave, R. (2013).
Emotion-focused therapy and dietary counseling for obese patients with binge
eating disorder. A propensity score-adjusted study. Psychotherapy and
Psychosomatic, 82, 193–194.
367
Cuzzolaro, M., Vetrone, G., Marano, G., & Garfinkel, P. E. (2006). The Body
Uneasiness Test (BUT). Development and validation of a new body image
assessment scale. Eating and Weight Disorders, 11, 1–13.
Dalle Grave, R., Calugi, S., Corica, F., Di Domizio, S., & Marchesini, G. (2009).
Psychological variables associated with weight loss in obese patients seeking
treatment at medical centers. Journal of the American Dietetic Association, 109,
2010–2016.
Dalle Grave, R., Cuzzolaro, M., Calugi, S., Tomasi, F., Temperilli, F., Marchesini, G.,
et al. (2007). The effect of obesity management on body image in patients
seeking treatment at medical centers. Obesity, 15(Silver Spring), 2320–2327.
Dalvit-McPhillips, S. (1984). A dietary approach to bulimia treatment. Physiology
and Behavior, 33, 769–775.
Elliott, R., & Greenberg, L. S. (2007). The essence of process-experiential/emotion-
focused therapy. American Journal of Psychotherapy, 61, 241–254.
Ellison, J. A., Greenberg, L. S., Goldman, R. N., & Angus, L. (2009). Maintenance of
gains following experiential therapies for depression. Journal of Consulting and
Clinical Psychology, 77, 103–112.
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for
eating disorders. A ‘‘transdiagnostic’’ theory and treatment. Behaviour Research
and Therapy, 41, 509–528.
First, M., Spitzer, R., Gibbon, M., & Williams, J. (1996). Structured clinical interview for
DSM-IV Axis I disorders-patient edition (SCID-I/P, Version 2.0). New York: New
York State Psychiatric Institute, Biometrics Research Department.
Foster, E. M. (2003). Propensity score matching. An illustrative analysis of dose
response. Medical Care, 41, 1183–1192.
Freitas, S. R., Lopes, C. S., Appolinario, J. C., & Coutinho, W. (2006). The assessment of
binge eating disorder in obese women. A comparison of the binge eating scale
with the structured clinical interview for the DSM-IV. Eating Behaviors, 7, 282–289.
Geliebter, A., & Hashim, S. A. (2001). Gastric capacity in normal, obese, and bulimic
women. Physiology & Behavior, 74, 743–746.
Gladis, M. M., Wadden, T. A., Foster, G. D., Vogt, R. A., & Wingate, B. J. (1998). A
comparison of two approaches to the assessment of binge eating in obesity.
International Journal of Eating Disorders, 23, 17–26.
Gormally, J., Black, S., Daston, S., & Rardin, D. (1982). The assessment of binge eating
severity among obese persons. Addictive Behaviors, 7, 47–55.
Gorman, B. S., & Allison, D. B. (1995). Measures of restrained eating. In D. B. Allison
(Ed.), Handbook of assessment for eating behaviors and weight-related problems
(pp. 149–184). Thousand Oaks, CA: Sage Publishing, Inc..
Greenberg, L. S. (2002). Emotion-focused therapy. Coaching clients to work through
their feelings. Washington, DC: American Psychological Association.
Greenberg, L. (2011). Emotion-focused therapy. Washington, DC: American
Psychological Association.
Greeno, C. G., Marcus, M. D., & Wing, R. R. (1995). Diagnosis of binge eating disorder.
Discrepancies between a questionnaire and clinical interview. International
Journal of Eating Disorders, 17, 153–160.
Hollon, S. D., & Ponniah, K. (2010). A review of empirically supported psychological
therapies for mood disorders in adults. Depression and Anxiety, 27, 891–932.
Karlsson, J., Persson, L. O., Sjostrom, L., & Sullivan, M. (2000). Psychometric properties
and factor structure of the Three-Factor Eating Questionnaire (TFEQ) in obese men
and women. Results from the Swedish Obese Subjects (SOS) study. International
Journal of Obesity and Related Metabolic Disorders, 24, 1715–1725.
Latner, J. D., Rosewall, J. K., & Chisholm, A. M. (2008). Energy density effects on food
intake, appetite ratings, and loss of control in women with binge eating disorder
and weight-matched controls. Eating Behaviors, 9, 257–266.
Latner, J. D., Stunkard, A. J., Wilson, G. T., Jackson, M. L., Zelitch, D. S., & Labouvie, E.
(2000). Effective long-term treatment of obesity. A continuing care model.
International Journal of Obesity and Related Metabolic Disorders, 24, 893–898.
Little, R. J., & Rubin, D. B. (2000). Causal effects in clinical and epidemiological
studies via potential outcomes. Concepts and analytical approaches. Annual
Review of Public Health, 21, 121–145.
Mannucci, E., Petroni, M. L., Villanova, N., Rotella, C. M., Apolone, G., & Marchesini, G.
(2010). Clinical and psychological correlates of health-related quality of life in
obese patients. Health Related Quality of Life Outcomes, 8, 90.
Mannucci, E., Ricca, V., Barciulli, E., Di Bernardo, M., Travaglini, R., Cabras, P. L., &
Rotella, C. M. (1999). Quality of life and overweight. The obesity related well-
being (Orwell 97) questionnaire. Addictive Behaviors, 24, 345–357.
Marano, G., Cuzzolaro, M., Vetrone, G., Calugi, S., Dalle Grave, R., Marchesini, G.,
et al. (2007). Further validation study of the Body Uneasiness Test (BUT) in a
clinical sample of 1922 adult obese subjects. Eating and Weight Disorders, 12,
70–82.
Marcus, M., Wing, R., & Fairburn, C. G. (1995). Cognitive behavioral treatment of
binge eating vs. behavioral weight control on the treatment of binge eating
disorder. Annals of Behavioral Medicine, 17.
Masheb, R. M., Grilo, C. M., & Rolls, B. J. (2011). A randomized controlled trial for
obesity and binge eating disorder. Low-energy-density dietary counseling and
cognitive-behavioral therapy. Behaviour Research and Therapy, 49, 821–829.
Minniti, A., Bissoli, L., Di Francesco, V., Fantin, F., Mandragona, R., Olivieri, M.,
Fontana, G., Rinaldi, C., Bosello, O., & Zamboni, M. (2007). Individual versus
group therapy for obesity. Comparison of dropout rate and treatment outcome.
Eating and Weight Disorders, 12, 161–167.
Munsch, S., Meyer, A. H., Quartier, V., & Wilhelm, F. H. (2011). Binge eating in binge
eating disorder. A break-down of emotion regulatory process? Psychiatry Research.
Pascual-Leone, A., Bierman, R., Arnold, R., & Stasiak, E. (2011). Emotion-focused
therapy for incarcerated offenders of intimate partner violence. A 3-year
outcome using a new whole-sample matching method. Psychotherapy Research,
21, 331–347.
368 A. Compare et al. / Appetite 71 (2013) 361–368
Petroni, M. L., Villanova, N., Avagnina, S., Fusco, M. A., Fatati, G., Compare, A., &
Marchesini, G. (2007). Psychological distress in morbid obesity in relation to
weight history. Obesity Surgery, 17, 391–399.
Ricca, V., Castellini, G., Lo Sauro, C., Ravaldi, C., Lapi, F., Mannucci, E., Rotella, C. M., &
Faravelli, C. (2009). Correlations between binge eating and emotional eating in a
sample of overweight subjects. Appetite, 53, 418–421.
Robinson, A. L., McCague, B., & Whissell, C. (2012). Single-case investigation of an
emotion-focused therapy group for anxiety and depression. International Journal
of Integrative Psychotherapy, 3, 59–81.
Rubin, D. B. (2007). The design versus the analysis of observational studies for
causal effects. Parallels with the design of randomized trials. Statistics in
Medicine, 26, 20–36.
Safer, D. L., Robinson, A. H., & Jo, B. (2010). Outcome from a randomized controlled
trial of group therapy for binge eating disorder. Comparing dialectical behavior
therapy adapted for binge eating to an active comparison group therapy.
Behavior Therapy, 41, 106–120.
Stunkard, A. J., & Messick, S. (1985). The three-factor eating questionnaire to
measure dietary restraint, disinhibition and hunger. Journal of Psychosomatic
Research, 29, 71–83.
Stunkard, A. J., & Messick, S. (1988). The eating inventory. San Antonio, TX:
Psychological Corporation.
Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for
binge eating disorder. Journal of Consulting and Clinical Psychology, 69,
1061–1065.
Watson, J. C., Gordon, L. B., Stermac, L., Kalogerakos, F., & Steckley, P. (2003).
Comparing the effectiveness of process-experiential with cognitive-behavioral
psychotherapy in the treatment of depression. Journal of Consulting and Clinical
Psychology, 71, 773–781.
Whiteside, U., Chen, E., Neighbors, C., Hunter, D., Lo, T., & Larimer, M. (2007).
Difficulties regulating emotions. Do binge eaters have fewer strategies to
modulate and tolerate negative affect? Eating Behaviors, 8, 162–169.
Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E.,
Dounchis, J. Z., Frank, M. A., Wiseman, C. V., & Matt, G. E. (2002). A randomized
comparison of group cognitive-behavioral therapy and group interpersonal
psychotherapy for the treatment of overweight individuals with binge-eating
disorder. Archives of General Psychiatry, 59, 713–721.
Wilson, G. T., Fairburn, C. C., Agras, W. S., Walsh, B. T., & Kraemer, H. (2002).
Cognitive-behavioral therapy for bulimia nervosa. Time course and
mechanisms of change. Journal of Consulting and Clinical Psychology, 70,
267–274.
Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating
disorders. American Psychologist, 62, 199–216.
Wilson, G. T., Wilfley, D. E., Agras, W. S., & Bryson, S. W. (2010). Psychological
treatments of binge eating disorder. Archives of General Psychiatry, 67, 94–101.
Wiser, S., & Telch, C. F. (1999). Dialectical behavior therapy for binge-eating
disorder. Journal of Clinical Psychology, 55, 755–768.