REGULAR ARTICLE

Emotional Overeating and its Associations with Eating Disorder Psychopathology among Overweight Patients with Binge Eating Disorder
Robin M. Masheb, PhD* Carlos M. Grilo, PhD
ABSTRACT Objective: The current study examined emotional overeating in overweight patients with binge eating disorder (BED). A new measurethe Emotional Overeating Questionnaire (EOQ)was developed to measure the frequency of overeating in response to emotions. The internal consistency, test-retest reliability, and factor structure of this measure were examined, and its associations with eating disorder psychopathology, depression, and gender were explored. Method: Two hundred twenty consecutive overweight (body mass index [BMI] ! 25) treatment-seeking BED patients (48 men and 172 women) were administered the EOQ, which assesses overeating frequency in response to six emotions (anxiety, sadness, loneliness, tiredness, anger, and happiness). A subset of patients (n 83) completed the measure again approximately 1 week later. BMI was measured, and participants completed measures of eating disorder psychopathology. Results: The EOQ was internally consistent (a .85), its items were significantly and moderately correlated (range .32 to .70) with each other, and principal components analysis revealed one factor accounting for 58% of the variance. The EOQ items and total score were characterized by good test-retest reliability (intraclass correlation coefficients [ICCs] ranged from .62 to .73). Significant correlations were found between the emotional overeating items and total score, and binge frequency, eating disorder features, and depressive symptomatology. Emotional overeating was unrelated to BMI, and men and women reported similar rates of emotional overeating. Conclusion: Emotional overeating was significantly associated with binge frequency, eating disorder features, and depression, but was not related to BMI or gender. 2005 by Wiley Periodicals, Inc. Keywords: binge eating disorder; emotional eating; assessment; measurement; obesity

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Introduction
Despite the clinical interest overeating in response to emotions, and the investigation of emotions as triggers for other behaviors (e.g., substance use), there has been a surprising lack of attention to this construct in the binge eating disorder (BED) and eating disorder literature. The BED diagnosis, as defined in the 4th ed. of the Diagnostic and
Accepted 15 February 2005 Supported by Grant DK 49587 from the National Institutes of Health and by the Donaghue Medical Research Foundation. *Correspondence to: Robin M. Masheb, PhD, Department of Psychiatry, Yale University School of Medicine, 301 Cedar Street, P.O. Box 208098, New Haven, CT 06520-8090. E-mail: robin.masheb@yale.edu Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut Published online 17 October 2005 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/eat.20221 2005 Wiley Periodicals, Inc.

Statistical Manual of Mental Disorders (DSM-IV),1 includes recurrent episodes of binge eating during which there is a subjective sense of a lack of control. As noted in the DSM-IV,1 some individuals report that binge eating is triggered by dysphoric moods, such as depression and anxiety. Yet, there are few data to support the frequency with which this occurs, which moods may serve as triggers, and what factors may be associated with emotional overeating.2 Arnow et al.3 has articulated a number of reasons for the lack of knowledge regarding the relation between emotions and eating in obese individuals. First, the notion that obese individuals are more likely to eat in response to external cues rather than internal stimuli had been a major theoretical paradigm for many years.4,5 This paradigm stands in contradiction to a prominent role for emotions in relation to eating behavior. Second, the current dominant eating disorder theory, restraint theory, 141

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has been widely applied to the maintenance of BED and posits that negative moods play a secondary role to dieting.6 Finally, it has been speculated that the psychoanalytic writings of emotional eating may have also dampened scientific interest in this area.3 Existing measures of emotional eating include the Three-Factor Eating Questionnaire (TFEQ7), the Dutch Eating Behavior Questionnaire (DEBQ8), and the Emotional Eating Scale (EES3). The TFEQ has a Disinhibition subscale that has been described as a two-factor scale,9 one being Emotional Eating. However, the six items are limited by the true-false response set for items such as, When I feel anxious, I find myself eating. Arnow et al.3 developed the EES and reported adequate psychometrics in a sample of obese binge eating females. Subjects were asked to rate their desire or urge to eat on a 5-point scale (from no desire to eat to an overwhelming urge to eat) for 25 emotions. The DEBQ and the EES items are based on the desire to eat, rather than on the frequency of eating in response to emotions. The use of a frequency response set has become standard practice in the eating disorder literature.10 In addition, all three existing instrumentsthe TFEQ, the DEBQ, and the EESmeasure eating rather than overeating. To date, there are no known measures that assess the frequency of emotional overeating. The purpose of the current study was to examine the frequency of emotional overeating in a sample of overweight patients with BED. A new measure, called the Emotional Overeating Questionnaire (EOQ), was developed that measures the frequency of overeating in response to emotions during the past 28 days. The internal consistency and testretest reliability of the EOQ were examined in patients with BED. In addition, the factor structure of the measure and associations with eating disorder symptomatology, depression, and gender were explored.

problems, or hypoglycemia) that influence weight or eating, and severe current psychiatric conditions requiring different treatments (psychosis, bipolar disorder, substance dependence, or suicidality). Written informed consent was obtained from all participants. The participant group had a mean age of 45.2 years (SD 8.8), and 79.6% (n 175) were Caucasian, 10.9% (n 24) were African American, 8.2% (n 18) were Hispanic American, and 1.4% (n 3) were other. Overall, total of 84.5% (n 186) attended or finished college. The mean BMI was 36.4 (SD 6.8). Measures The EOQ is a six-item self-report questionnaire developed for the current study to measure of overeating in response to emotions. Items, and the responses for the items, were developed with language similar to that used in the Eating Disorder Examination-Questionnaire (EDEQ). Each item begins with, On how many days out of the past 28 days have you eaten an unusually large amount of food, given the circumstances, in response to feelings of. . . Each of six emotions is presented in all capital letters, followed by three more synonyms in parentheses and lower case as follows: (a) ANXIETY (worry, jittery, nervous), (b) SADNESS (blue, down, depressed), (c) LONELINESS (bored, discouraged, worthless), (d) TIREDNESS (worn-out, fatigued), (e) ANGER (upset, frustrated, furious), and (f) HAPPINESS (good, joyous, excited). The response set for the six items is a 7-point scale reflecting the frequency of days in which the behavior occurred in the past 28 days (i.e., 0 no days, 1 15 days, 2 612 days, 3 1315 days, 4 1622 days, 5 2327 days, and 6 every day). The total score is obtained by adding the responses of the six items and dividin by six. Higher scores reflect more frequent overeating. The use of a 28-day time frame and frequency response set was deemed important in the development of this measure as it has become standard practice in the eating disorder literature to anchor eating behaviors in this way.10 All 220 participants completed this measure at Time 1, and a subset of 83 consecutive participants completed this measure again at Time 2, approximately 1 week later. The EDE-Q12 is a 32-item self-report measure of eating disorder psychopathology based on the Eating Disorder Examination interview (EDE13). The EDE-Q assesses the frequency of different forms of overeating behaviors, including objective bulimic episodes (i.e., binge eating defined as consuming an unusually large amount of food, given the circumstances, with a subjective feeling of loss of control). The EDE-Q also comprises four subscales, including Dietary Restraint, Weight Concern, Shape Concern, and Eating Concern. Higher scores reflect greater binge frequency or eating disorder severity. In this patient study group, coefficient alphas for the EDE-Q subscales are as follows: .75 for Dietary Restraint,
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Method
Participants Participants were a consecutively evaluated series of 220 treatment-seeking overweight (body mass index [BMI; kg/m2] ! 25) adults (48 men and 172 women) who met DSM-IV1 research criteria for BED. DSM-IV diagnoses were based on the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P11). Exclusionary criteria were any concurrent treatment for weight or eating, medical conditions (diabetes, thyroid

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.56 for Weight Concern, .67 for Shape Concern, and .72 for Eating Concern. The EDE-Q has received empirical support for use with BED.14,15 The TFEQ7 is a 51-item self-report questionnaire that is a widely used and established measure of eating problems.16 The measure has three subscales reflecting the following disordered eating domains: Cognitive Restraint, Disinhibition, and Hunger. Higher scores reflect worse eating problems. In this patient study group, coefficient alphas for the scales are as follows: .67 for Cognitive Restraint, .50 for Disinhibition, and .69 for Hunger. The TFEQ has demonstrated clinical utility for treatment studies of overeating and obesity.17 The Beck Depression Inventory (BDI18) is a 21-item self-report measure used to evaluate the cognitive, affective, motivational, and somatic symptoms of depression. Higher scores reflect greater depressive symptomatology and negative affect. Psychometric evaluations have reported adequate internal consistency, retest reliability, and convergent validity.18 In this patient study group, the coefficient alpha is .88. For each item, participants are asked to pick one statement out of a group of statements (e.g., I do not feel sad; I feel sad; I am sad all the time and I cant snap out of it; or I am so sad or unhappy that I cant stand it) that best describes how they have been feeling during the past week. This study was reviewed and approved by an institutional review board.

Table 2 summarizes the test-retest study of the EOQ in a subset of 83 patients. Means and standard deviations for each of the six items and the total score at Time 1 and Time 2 are shown along with intraclass correlation coefficients (ICCs). ICCs, which ranged from .62 to .73 (p < .0001), demonstrate adequate test-retest reliability for these items and for the total score. Exploratory principal components factor analysis revealed a one-factor solution (eigenvalue 3.484) accounting for 58.07% of the variance. Factor loadings for the individual items were as follows: .77 for anxiety, .86 for sadness, .79 for loneliness, .74 for tiredness, .81 for anger, and .58 for happiness. This supports the unidimensional structure of the instrument.
Frequency of Emotional Overeating and Gender Differences

For the overall sample, overeating in response to anxiety was the most frequently cited emotion (M 2.75, SD 1.94) occurring on approximately one-half the days, and overeating in response to happiness (M 1.40, SD 1.61) was the least frequently cited emotion occurring on approximately one-fourth the days in the past 28 days (Table 3). Table 3 also shows that men and women did not differ significantly on the EOQ with the exception of loneliness. Women (M 2.77, SD 1.97) reported overeating more frequently in response to loneliness than men (M 2.06, SD 1.88), F(1, 219 4.89, p .028.
Associations with Emotional Overeating

Results
Psychometric Findings

Table 1 shows a correlation analysis of the EOQ items and total score. The six items were moderately and significantly correlated with one another (Pearson product-moment correlation coefficients (rs) ranging from .32 to .70, p < .0001) and with the total score (rs ranging from .60 to .84, p < .0001). The internal consistency of the measure was high with a .85.
TABLE 1.

A correlation analysis was performed with the EOQ, and BMI, binge episodes, eating disorder features, and depressive symptomatology (Table 4). The six emotional overeating items were unrelated to BMI. All six items and the total score were significantly related to the frequency of binge episodes (rs ranging from .17 to .31, p < .05) and to most eating disorder symptomatology (i.e., Eating Concern, Shape Concern, Weight Concern, Disinhibition, and Hunger; rs ranging from .14 to .39,

Correlation coefficients among the emotional overeating variables (N = 220) Anxiety Sadness Loneliness Tiredness Anger Happiness Total Score

Emotional eating variables Anxiety Sadness Loneliness Tiredness Anger Happiness Total score *p < .0001.

.67* .45* .50* .53* .33* .77*

.70* .48* .65* .32* .84*

.46* .58* .38* .79*

.53* .43* .75*

.37* .80*

.60*

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MASHEB AND GRILO TABLE 2. Means, standard deviations, and intraclass correlation coefficients (ICCs) for test-retest reliability (n = 83) Time 1 M Anxiety Sadness Loneliness Tiredness Anger Happiness Total score *p < .0001. 3.06 2.88 2.72 2.28 2.52 1.75 2.53 (SD) (1.95) (1.98) (2.08) (2.11) (1.95) (1.72) (1.56) M 3.01 2.64 2.34 2.39 2.58 1.82 2.45 Time 2 (SD) (1.75) (1.95) (1.98) (2.01) (1.94) (1.77) (1.47) ICC .64* .72* .63* .62* .66* .63* .73*

Conclusion
The current study represents a preliminary investigation of emotional overeating in overweight men and women with BED. The development and psychometric investigation of a measure of emotions for overeating behaviors seemed indicated given that it has been presumed that some individuals with BED report binge eating triggered by dysphoric moods.1 Clinically, we have found that some participants in our BED trials self-identify as emotional eaters. We developed the EOQ, a measure specifically designed to assess the frequency that patients with BED report overeating in response to emotions. Overeating in response to anxiety was the most frequently cited emotion and occurred on approximately one-half the days, whereas overeating in response to happiness was the least frequently cited emotion and occurred on approximately onefourth the days during the previous month. Overeating in response to sadness, loneliness, tiredness, and anger occurred between one-half and onefourth the days during the previous month. With regard to its psychometric properties, the EOQ was found to be internally consistent. The six items were moderately and significantly correlated with one another, suggesting that they are related but not redundant. Factor analysis revealed a single-factor solution that accounted for 58% of the variance. Specific associations with binge frequency, eating disorder features, and depressive symptomatology were found to be consistent across the six emotions and the total score. The EOQ items and total score demonstrated good test-retest reliability. These findings suggest that examining the specific emotions may not be as important as examining emotional overeating globally, thus supporting the use of a total score for this instrument. Alternatively, the variation in correla-

TABLE 3. Means, standard deviations, and analyses of variance (ANOVAs) comparing males and females Overall Sample (N 220) M Anxiety Sadness Loneliness Tiredness Anger Happiness Total score 2.75 2.66 2.61 2.06 2.27 1.40 2.29 (SD) (1.94) (1.91) (1.97) (2.02) (1.92) (1.61) (4.44) Male (n 48) M 2.48 2.31 2.06 1.87 2.02 1.44 2.03 (SD) (1.70) (1.76) (1.88) (2.00) (1.90) (1.60) (4.32) Female (n 172) M 2.83 2.76 2.77 2.11 2.34 1.40 2.37 (SD) (2.00) (1.94) (1.97) (2.03) (1.92) (1.62) (1.47) ANOVA F 1.24 2.04 4.89 0.51 1.02 0.03 2.03 p .267 .155 .028 .476 .313 .873 .155

p < .05). Greater emotional overeating was related to more frequent binge episodes and more frequent and severe eating disorder symptomatology. The six emotional overeating items were unrelated to restraint, measured with both the EDE-Q and the TFEQ. In addition, the six emotional overeating items and the total score were significantly correlated with the BDI (rs ranging from .31 to .49, p < .001), such that greater emotional overeating was related to greater depressive symptomatology.

TABLE 4.

Correlation coefficients for the emotional overeating variables with eating-related measures (N = 220a) Anxiety Sadness .04 .31*** .11 .38*** .34*** .39*** .06 .25*** .30*** .46*** Loneliness .09 .25*** .08 .27*** .24*** .28*** .08 .12 .25*** .45*** Tiredness .10 .17* .06 .22*** .15* .22*** .11 .21** .34*** .31*** Anger .02 .28*** .13 .28*** .28*** .30*** .10 .28*** .22*** .42*** Happiness .18** .17** .03 .14* .21** .16* .20** .14* .19** .25*** Total score .08 .31*** .11 .39*** .32*** .36*** .11 .27*** .35*** .49***

BMI EDE-Q binge episodes Eating disorder symptomatology EDE-Q Restraint EDE-Q Eating Concern EDE-Q Shape Concern EDE-Q Weight Concern TFEQ Cognitive Restraint TFEQ Disinhibition TFEQ Hunger Beck Depression Inventory

.03 .25*** .15* .38*** .26*** .30*** .04 .25*** .29*** .33***

Note: BMI body mass index; EDE-Q Eating Disorder Examination-Questionnaire; TFEQ Three-Factor Eating Questionnaire. a N 220 for all variables except BMI (N 212), EDE-Q objective binge episodes (N 218), and TFEQ Cognitive Restraint (N 219). *p < .05. **p < .01. ***p < .001.

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tions, coupled with the adequate test-retest stability observed for the specific emotions, suggests that they can potentially be considered separately in future research. Men and women with BED differed little in their reports of overeating in response to emotional triggers. One exception was that women were more likely to report eating in response to loneliness than men. This finding differed from a previous study of men and women with BED using the EES, which reported that women were more likely to report overeating in response to a range of negative emotions, particularly anxiety, anger and frustration, and depression.19 Our measure assessed the frequency of eating in response to emotions whereas the Arnow et al.3 measure assessed the urge to eat in response to emotions. In other words, it may be that women reported a greater urge to eat in response to emotions, but engage in this behavior at a similar frequency as men. Another important distinction is that our measure asked about eating an unusually large amount of food (i.e., overeating), whereas the Arnow et al.3 items asked about eating. Thus, it may be that women and men may binge eat or overeat with a similar frequency in response to emotions, but women may generally eat more than men in response to emotions. As expected, emotional overeating was related to the frequency of binge episodes and disinhibition, but it was not related to restraint. This suggests that emotional overeating is an important area of investigation as a trigger for binge eating and disinhibition among individuals with BED. Similarly, Arnow et al.3 found associations between binge eating and disinhibition, but not restraint, for the three factors (i.e., Anger/Frustration, Anxiety, and Depression) of the EES. We also found associations between emotional overeating and the more cognitive features of eating disorders, such as eating concern, and overevaluation of weight and shape. Of note was the absence of an association between BMI and emotional overeating. There are several potential limitations to the current study. First, only six emotions were chosen for this measure based on clinical judgment. Rather than trying to include more items reflecting diverse emotions, we selected items representing a range of positive and negative emotions that vary in energy/ arousal. We attempted to create more of a behavioral measure of emotional overeating based on the frequency of eating in response to emotions, rather than a more cognitive measure based on the urge to eat in response to emotions. However, this measure was also based on retrospective recall of the past 28 days, thus precluding any specific statements that
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these emotions actually served as proximal antecedents or triggers for the overeating.3 Such studies would require application of methods such as ecologic momentary assessment.20 In addition, the measure developed for the current study did not take into account that overeating episodes might be triggered by a combination of emotions. Finally, the generalizability of our findings is limited to treatment-seeking overweight individuals with BED. In summary, this report details the development of the EOQ, a measure to assess the frequency of overeating in response to six emotions (i.e., anxiety, sadness, loneliness, tiredness, anger, and happiness), and provides findings based on a study group of treatment-seeking overweight men and women with BED. The EOQ demonstrated high internal consistency and adequate test-retest reliability, and concurrent validity with measures of binge frequency, eating disorder features, and depressive symptomatology. The item level can be maintained for its clinical utility, or a single total score can be used since the measure yields a single factor. Given the high frequency of emotional overeating reported in this sample (i.e., between onefourth and one-half the days of the previous month for each of the six emotions), future research should investigate whether treatment for BED is associated with changes in the frequency of emotional overeating, as measured by this scale.

References
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994. 2. Grilo CM, Shiffman S, Carter-Campbell JT. Binge eating antecedents in normal-weight nonpurging females: is there consistency? Int J Eat Disord 1994;16:239. 3. Arnow B, Kenardy J, Agras WS. The emotional eating scale: the development of a measure to assess coping with negative affect by eating. Int J Eat Disord 1995;18:79. 4. Schacter S, Goldman R, Gordon A. Effects of fear, food deprivation, and obesity on eating. J Pers Soc Psychol 1968;10:91. 5. Nisbett RE. Hunger, obesity, and the ventromedial hypothalamus. Psychol Rev 1972;79:433. 6. Polivy J, Herman CP. Dieting and binging: a causal analysis. Am Psychol 1985;40:193. 7. Stunkard AJ, Messik S. The Three Factor Eating Questionnaire to measure dietary restraint, disinhibition, and hunger. J Psychosom Res 1985;29:71. 8. Van Strien T, Frijters JER, Bergers GPA, et al. The Dutch Eating Behavior Questionnaire (DEBQ) for assessment of restrained, emotional, and external eating behavior. Int J Eat Disord 1986;5:295. 9. Ganley RM. Emotional eating and how it relates to dietary restraint, disinhibition, and perceived hunger. Int J Eat Disord 1988;7:635.

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10. Wilson GT. Assessment of binge eating. In: Fairburn CG, Wilson GT, editors. Binge eating: nature, assessment, and treatment. New York: Guilford Press; 1993, p 227. 11. First MB, Spitzer RL, Gibbon M, et al. Structured Clinical Interview for DSM-IV Axis I Disorders - Patient Version (SCID-I, Version 2.0). New York: New York State Psychiatric Institute; 1996. 12. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord 1994;16:363. 13. Fairburn CG, Cooper Z. The Eating Disorder Examination. 12th ed. In: Fairburn CG, Wilson GT, editors. Binge eating: nature, assessment, and treatment. New York: Guilford Press; 1993, p 317. 14. Grilo CM, Masheb RM, Wilson GT. A comparison of different methods for assessing the features of eating disorders in patients with binge eating disorder. J Consult Clin Psychol 2001;69:317. 15. Grilo CM, Masheb RM, Wilson GT. Different methods for assessing the features of eating disorders in patients with binge eating disorder. Obes Res 2001;9:418. 16. Allison G, Kalinsky LB, Gorman BS. A comparison of the psychometric properties of the three measures of dietary restraint. Psychol Assess 1992;4:391. 17. Foster GD, Wadden TA, Swain RM, et al. The eating inventory in obese women: clinical correlates and relationship to weight loss. Int J Obes Rel Metab Disord 1998;22:778. 18. Beck AT, Steer RA, Garbin M. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988;8:77. 19. Tanofsky MB, Wilfley DE, Spurrell EB, et al. Comparison of men and women with binge eating disorder. Int J Eat Disord 1997;21:49. 20. Greeno CG, Wing RR, Shiffman S. Binge antecedents in obese women with and without binge eating disorder. J Consult Clin Psychol 2000;68:95.

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