Introduction. Method. CM Grilo 1 * and RM Masheb 1

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1 (2000) 24, 404±409 ß 2000 Macmillan Publishers Ltd All rights reserved 0307±0565/00 $ in outpatients with binge eating disorder CM Grilo 1 * and RM Masheb 1 1 Yale Psychiatric Institute and Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA OBJECTIVE: To examine the potential signi cance of the sequence of the onset of dieting and binge eating in binge eating disorder (BED). DESIGN: BED patients were interviewed and completed a battery of psychometrically well-established measures of current eating behaviors, eating disorder psychopathology, and associated psychological functioning. SUBJECTS: Participants were 98 consecutive outpatients with BED evaluated for a clinical trial. MEASURES: Interview data, self-report measures and measured body weight were examined. RESULTS: Participants who reported that dieting preceded binge eating (DIET rst, 65%) were compared to those who reported that binge eating preceded their rst diet (BINGE rst, 35%). The study groups did not differ in demography, current or highest body mass index, current eating behaviors or psychopathology, or psychological functioning. The two groups did not differ in age of rst diet; however, the BINGE rst group was signi cantly younger when rst overweight, at onset of binge eating, and at onset of BED diagnosis. The BINGE rst group reported a higher frequency of being teased about their weight. CONCLUSIONS: A substantial subgroup of BED patients report that binge eating preceded their rst diet. This nding, which replicates previous reports for BED and appears higher than that generally reported for bulimia nervosa, may have implication for etiologic models of binge eating. (2000) 24, 404±409 Keywords: binge eating disorder; dieting; onset; etiology Introduction Binge eating disorder (BED) is a new eating disorder category included in the DSM-IV in Appendix B re ecting `criteria sets provided for further study'. The multisite eld trials of the proposed diagnostic criteria 1,2 and subsequent studies have reported general, albeit mixed, support for the validity of the BED diagnosis (see Ref 3). Many questions remain regarding the development and psychopathology of BED. 3±5 Restrictive dieting is central to most etiologic and risk models of eating disorders. 6 Patients with eating disorders generally have extensive histories of dieting, and a period of restrictive dieting frequently precedes the onset of bulimia nervosa in the vast majority of cases. 7 However, some investigators have reported that roughly 15% of patients with bulimia nervosa were not dieting at the onset of binge eating 8,9 and that this subgroup may differ from the `typical cases' with bulimia nervosa. 9,10 The emerging empirical literature for BED, in contrast to that for bulimia nervosa, suggests that binge eating may precede dieting in many cases. Wilson and colleagues 11 found that only 8.7% of obese binge eaters entering a weight control program *Correspondence: CM Grilo, Yale Psychiatric Institute, 184 Liberty Street, New Haven, CT 06519, USA. Received 6 April 1999; revised 14 September 1999; accepted 1 November 1999 reported that they had been on a strict diet at the time they began binge eating and that 64% reported that the binge eating preceded their obesity. In a study of 30 females enrolled in a BED treatment program, 44% reported binge eating by age 16 whereas only 28% reported signi cant dieting and weight loss by age 16; 12 binge eating preceded obesity by several years in the majority of cases. A recent study with 87 BED patients entering a clinical trial found that 55% of cases reported binge eating prior to dieting. 13 These ndings are generally consistent with those reported in the DSM-IV eld trials. 2 Given the centrality of dieting or restraint in etiologic models of bulimia nervosa 7 and the emerging possibility of a potentially different sequence for 11 ± 13 binge eaters who do not purge, the current study aimed to examine the potential signi cance of the sequence of the onset of dieting or binge eating in BED. Method Subjects were 98 adults (80 females and 18 males) consecutively evaluated for outpatient clinical trials who met DSM-IV criteria for BED. Subjects were aged 18 ± 60 y (mean ˆ 41.6, s.d. ˆ 9.9), 90% (n ˆ 88) were Caucasian, 57% (n ˆ 56) were married, and 86% (n ˆ 84) either attended or graduated from college.

2 Written informed consent was obtained from participants. DSM-IV axis I psychiatric diagnoses were derived by consensus and based on the independent administration of the SCID-I 14 and a clinical interview by trained and monitored Ph.D.-level research clinicians. DSM-IV axis II personality disorders were assigned based on the administration of the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV), 15 a semi-structured diagnostic interview that assesses all 12 (10 recognized and two research diagnoses) personality disorders. The SCID-I and DIPD-IV interviews were performed by three experienced Ph.D.-level research clinicians with training in the SCID-I and eating disorders. The three SCID-I interviewers for this study were evaluated as part of a larger inter-rater reliability study involving 12 interviewers. 16 Interrater reliability (calculated using 84 pairs of raters) Ð as re ected by kappa coef cient Ð for eating disorder diagnoses was 0.77 for all raters and was 1.0 for the BED diagnosis for the three interviewers in the present study. Kappas for the personality disorder diagnoses ranged from 0.58 to The clinical interviews were performed by three additional Ph.D. research clinicians, including the two authors (CMG, RMM). The clinical interviews were performed using a structured format to obtain the historical variables of interest. Inter-rater reliability for these highly structured interviews was not assessed. The variables of principal interest here (ie, onset, sequence, etc) represent concrete variables rather than dimensional or clinical factors that require complex judgements for ratings. Nonetheless, the rst author reviewed the administration of the interviews with the research clinicians on an on-going basis in an attempt to minimize potential drift. Diagnoses were further con rmed by relevant portions of two self-report measures, the Eating Disorder Examination Questionnaire (EDE-Q 17 ) and the Questionnaire For Eating and Weight Practices Ð Revised (QEWP-R 4 ), which were administered to assess the history and current eating-related functioning of the participants. The EDE-Q 17 is the self-report version of the investigator-based Eating Disorder Examination interview. 18 The EDE-Q assesses the frequency of the core behavioral features (ie objective binge episodes and subjective binge episodes) and intensity of eatingrelated psychopathology producing four subscales (ie restraint, eating concerns, weight concerns and shape concerns scales). The EDE-Q has been empirically validated with BED 19,20 and BN. 17,21 The QEWP-R, 4 employed in the DSM-IV eld trials, 2 assesses each criterion of BED including the stipulated 6-month duration. The QEWP-R also assesses a number of relevant historical variables to this study, including age at which rst overweight by 10 pounds and the number of 20-pound weight loss ± regain cycles. The clinical interviewer checked the relevant QEWP-R 4 items with participants and also inquired about the following variables following a structured format: age of rst diet, and age of onset for regular binge eating (once per week). The interviewer obtained actual weights using a medical balance beam scale and calculated body mass index (BMI; weight= by height 2 ). The independently administered SCID-I 14 assessed for age of onset of BED diagnosis at threshold DSM-IV criteria (ie 2 days with binges per week for at least 6 months). In addition, several psychometrically sound selfreport measures of important associated domains were administered. These were selected based on conceptual and empirical grounds (see Ref 3) and to allow for comparison with previous work. 9,12,13 (1) The Physical Appearance-Related Teasing Scale (PARTS 22 ) is an 18-item measure of the frequency of being teased while growing up. The PARTS has two subscales: (a) weight=size teasing and (b) general appearance teasing. Higher scores re ect higher frequencies of reported teasing experiences. The PARTS is psychometrically sound, 22 and has been used in nonclinical 23,24 and clinical studies 25 of obesity, eating problems and body image. Childhood teasing about weight=shape has been identi ed as a possible risk factor for BED. 5,25 (2) The Body Shape Questionnaire (BSQ 26 ) is a 34- item measure of body dissatisfaction. The BSQ assesses the frequency of preoccupation with and distress about body size=shape. Subjects rate items (eg `Have you felt so bad about your shape that you have cried?') on a scale from 1 (never) to 6 (always); thus higher scores re ect greater body dissatisfaction. The BSQ is a widely used instrument in studies of eating and weight disorders. 9,23 ± 25 (3) The Three Factor Eating Questionnaire (TFEQ 26 ) is a widely used psychometrically sound measure, with three subscales to tap important eating disordered domains: dietary restraint, disinhibition and hunger. The TFEQ is widely used in obesity and eating disorder studies. 9,28 (4) The Beck Depression Inventory (BDI 29 ) 21-item version was employed to assess level of depression. The BDI is a psychometrically sound, widely used inventory of the cognitive, affective, motivational and somatic symptoms of depression. Higher scores re ect higher levels of depression; a score of 16 or higher is generally recommended as a cutoff point for major depression. 29,30 (5) The Rosenberg Self-Esteem Scale (RSE 31 )isa widely used 10-item measure of global selfesteem with established reliability and validity. 31,32 Subjects rate the items (eg `On the 405

3 406 whole, I am satis ed with myself') on a scale from 1 (strongly agree) to 4 (strongly disagree). Scoring procedures result in higher, scores re ecting higher self-esteem. (6) The Drug Abuse Screening Test (DAST 33 )isa 27-item self-report screening instrument for drug abuse and related adverse consequences experienced secondary to the drug use. The DAST has demonstrated reliability and validity and good predictive power for substance abuse problems in varied patient populations. 33,34 (7) The Self-Consciousness Scale (SCS 35 ) contains three scales, two of which were administered here: (a) the Public Self- Consciousness Scale contains seven items that measure awareness of others' reactions to the self (eg `I'm concerned about what other people think of me'), and (b) the Social Anxiety Scale contains six items that measure level of discomfort experienced in the presence of others (eg `It takes me time to overcome my shyness in public situations'). Subjects rate the items on a scale from 0 (extremely uncharacteristic) to 4 (extremely characteristic of self). The SCS has demonstrated good reliability and validity. 35 The SCS has been found to be associated with body dissatisfaction in bulimia nervosa 36 and obesity 37 andhasbeenfoundtobehigherin obese binge eaters than obese nonbinge eaters. 37 Results Sixty-four of the 98 participants (65%) who reported that dieting preceded binge eating (DIET rst group) were compared to the 34 participants (35%) who reported that binge eating preceded their rst diet (BINGE rst group). The DIET rst and BINGE rst groups did not differ in current age (41.1 y vs 42.7 y; F(1, 97) ˆ 0.57, ns) or gender (81% female vs 82% female; chi-square (1) ˆ 0.02, ns). The two study groups were characterized by similar axis I psychiatric and axis II personality disorder frequencies. The two study groups did not differ in the distribution of major depression (w 21 ˆ 0.47, ns), dysthymia (w 21 ˆ 0.12, ns), panic disorder (w 2 (1) ˆ 0.00, ns), social phobia (w 2 (1) ˆ 1.49, ns), obsessive compulsive disorder (w 2 (1) ˆ 0.41, ns), post-traumatic stress disorder (w 2 (1) ˆ 0.19, ns), or substance use disorders (w 2 (1) ˆ 0.88, ns). No differences in the distribution of any lifetime psychiatric disorders were observed. Complete axis II personality disorder data derived with the DIPD-IV were available for 74 of the participants. The two study groups did not differ signi cantly in whether any personality disorder was diagnosed (w 2 (1) ˆ 0.29, ns) or in the distribution of speci c cluster A (w 2 (1) ˆ 0.01, ns), cluster B (w 2 (1) ˆ 0.63), or cluster C (w 2 (1) ˆ 1.56, ns) personality disorder diagnoses. Table 1 summarizes the developmental variables, current eating disturbance, and current psychological Table 1 Comparison of BED patients who reported rst onset of diet vs binge eating Overall Diet First Binge First n ˆ 98 n ˆ 64 n ˆ 34 ANOVA M s.d. M s.d. M s.d. F(d.f. ˆ97) P Developmental variable Age of rst diet 16.6 (6.6) 16.4 (6.2) 17.1 (7.5) 0.20 ns Age of rst regular binge eating 19.4 (11.0) 24.9 (10.6) 11.6 (5.2) Age of rst overweight 14.6 (8.0) 15.8 (8.4) 12.4 (6.8) Age rst met BED diagnosis 23.1 (11.8) 25.8 (11.3) 17.8 (10.5) Current BMI 36.6 (9.2) 35.9 (8.8) 37.9 (9.9) 1.11 ns Highest adult BMI 38.6 (9.6) 37.9 (9.3) 39.9 (10.0) 0.95 ns No. of 20 lb weight cycles 3.1 (1.1) 3.1 (1.1) 3.1 (1.1) 0.00 ns Teasing history (PARTS-total): 38.8 (16.1) 36.5 (14.6) 43.2 (18.0) weight/size 28.2 (14.3) 25.7 (13.4) 32.7 (15.0) general appearance 10.7 (5.1) 10.8 (4.9) 10.4 (5.5) 0.09 ns Current eating disturbance EDE-Q: objective binge episodes/month 17.8 (12.3) 16.7 (9.5) 19.7 (16.2) 1.36 ns subjective binge episodes/month 5.3 (8.5) 5.2 (8.9) 5.5 (7.8) 0.03 ns dietary restraint 14.2 (7.8) 14.8 (7.7) 13.0 (7.9) 1.15 ns eating concern 20.5 (6.1) 20.7 (6.2) 19.9 (6.0) 0.41 ns weight concern 21.3 (5.1) 21.5 (5.4) 20.9 (4.7) 0.31 ns shape concern 40.6 (7.9) 41.2 (7.9) 39.5 (7.5) 1.05 ns Body Shape Questionnaire (26.2) (25.5) (27.4) 0.91 ns Three Factor Eating Questionnaire: cognitive restraint 8.7 (4.4) 9.4 (4.3) 8.2 (4.5) 1.59 ns disinhibition 14.1 (1.8) 14.3 (1.4) 13.7 (2.2) 3.17 ns hunger 9.8 (3.5) 9.6 (3.3) 10.1 (3.3) 0.40 ns Current psychological functioning: BDI 20.2 (9.7) 20.8 (9.9) 19.1 (9.5) 0.69 ns RSE 26.3 (6.0) 26.3 (6.2) 26.3 (5.5) 0.00 ns DAST 1.8 (3.4) 1.5 (2.4) 2.4 (4.7) 1.35 ns SCS Ð Public self-consciousness 22.7 (4.1) 22.9 (3.9) 22.5 (4.5) 0.16 ns SCS Ð Social anxiety 15.8 (4.4) 15.8 (3.9) 15.8 (5.1) 0.00 ns

4 functioning ndings for the two study groups. Also shown in Table 1 are the statistical tests for signi cant differences (ANOVAs for continuous data). The DIET rst and BINGE rst groups did not differ in age of rst diet; however, the BINGE rst group was signi cantly younger when rst overweight, at onset of binge eating, and at onset of BED diagnosis. The BINGE rst group reported a higher frequency of being teased about their weight and size while growing up (PARTS). The two groups were similar in current body mass index (BMI) and highest lifetime BMI, current binge eating frequency (objective and subjective binge eating frequency on the EDE-Q), associated eatingrelated psychopathology (EDE-Q and TFEQ), body image dissatisfaction (BSQ), and current psychological functioning (BDI, RSE, DAST and SCS). We re-analyzed all of the data separately for females only (note that gender was not differentially distributed by onset of dõâet or binge eating as indicated above). When restricted to females (n ˆ 80), all of the overall nonsigni cant ndings remained nonsigni cant. In the case of signi cant ndings observed for the overall group, all of the comparison remained signi cant for females only. For females only, the BINGE rst group was signi cantly younger when rst overweight (M ˆ 11.2 (s.d. ˆ 6.1) vs M ˆ 16.7 (s.d. ˆ 8.4) y; F ˆ 8.79, P ˆ 0.004), at onset of binge eating (M ˆ 10.7 (s.d. ˆ 4.4) vs M ˆ 23.9 (s.d. ˆ 10.8) y; F ˆ 36.72, P < 0.000), and at onset of BED diagnosis (M ˆ 15.3 (s.d. ˆ 8.7) vs M ˆ 26.6 (s.d. ˆ 11.5) y; F ˆ 11.9, P < 0.001). For females, the BIN- GE rst group reported a higher frequency on the PARTS of being teased about their weight and size while growing up (M ˆ (s.d. ˆ 14.9) vs M ˆ (s.d. ˆ 11.9); F ˆ 7.34, P < 0.008). Discussion This study rigorously assessed a consecutive series of patients with BED at a university-based outpatient eating disorder program. Sixty- ve percent of patients reported that dieting preceded their binge eating and 35% reported that binge eating preceded their rst diet. Age of onset of binge eating and of BED differed signi cantly depending on whether dieting or binge eating began rst. Patients who began binge eating rst reported earlier onset of overweight, higher frequency of being teased about their weight and shape, and an earlier onset of BED diagnosis than those patients who reported dieting prior to their rst binge. No signi cant differences between the two study groups were observed in demography or gender, current BMI or highest BMI, weight cycling, eating behavior disturbances (binge eating frequency, overeating frequency, hunger, restraint, disinhibition), overvalued ideas regarding weight and shape, body image dissatisfaction, associated psychological domains (depression, self-esteem, drug problems, or self-consciousness), or in the distribution of DSM-IV psychiatric or personality disorders. Roughly one-third of BED patients reported regular binge eating prior to regular dieting. This nding, while slightly lower than reported previously for obese binge eaters 11,12 and BED, 13 is nonetheless considerably higher than the consistent nding that dieting precedes binge eating in the vast majority of bulimic cases. 9,10 Overall for the entire BED study group, the average age of rst overweight was 14.6 y, age of rst diet was 16.2 y, and age of binge eating was 19.4 y. This sequence, at rst glance, might be thought to be consistent with prevailing views that overweight leads to dieting which precipitates binge eating in vulnerable persons. However, 34% of the patients reported a sharp deviation from this pattern. For BED patients who report binge eating rst, the mean age of onset of binge eating was 11.6, the mean age of rst overweight was 12.4 y, and the mean age of rst diet was 17.1 y. In this pattern, binge eating leads to overweight which leads to dieting. This nding and ndings from other studies 10 suggest the importance of early interventions for binge eating. We found that BED patients who report binge eating rst reported a higher frequency of being teased about weight and size than BED patients who report dieting rst. This may be due to the nding that they were more likely to be overweight at an earlier age. Grilo and colleagues 25 reported that the frequency of being teased about weight and size while growing up was positively correlated with body dissatisfaction during adulthood in obese female patients. Moreover, early onset obesity was associated with greater body dissatisfaction, 25 a nding initially noted by Stunkard. 38,39 Fairburn and colleagues, 5 using a community-based case-control design, found that repeated exposure to negative comments about weight and shape emerged as a main risk factor that identi ed BED from healthy controls and from psychiatric controls. Compared to subjects with other psychiatric disorders, subjects with BED reported more childhood obesity and more teasing experiences. 5 It is possible, however, that the weight-related teasing was due to childhood overweight but unrelated to the binge eating per se. This nding merits further research to better determine the sequence and potential etiologic signi cance. Longitudinal prospective designs 40,41 with use of integrated and relevant comparison groups (eg Ref 5; see Ref 42) are needed to better establish signi cance and understand complex interplay of multiple variables. 43 The lack of differences in current body mass index (BMI), and the striking similarities in current eating behaviors, attitudes regarding weight=shape and psychological functioning replicate those previously reported for BED. 13 A similar report for bulimia nervosa 9 indicated that 16 bulimics who began binge 407

5 408 eating before dieting had higher body dissatisfaction and higher disinhibition than 81 bulimics who began binge eating after dieting; they too, however, failed to nd differences in current eating and binge eating behaviors or depression. These descriptive ndings may have prognostic signi cance. Agras and colleagues 44 reported that early onset binge eating predicted poor outcomes from psychological treatments otherwise characterized by impressive ef cacy. Future descriptive studies of the psychopathology of BED and of treatment outcome should consider age of onset and sequence of dieting vs binge eating. We observed no differences between the two groups in DSM-IV psychiatric or personality disorders. These ndings also generally replicate those previously reported 13 for most areas of DSM-III-R psychiatric functioning. Spurrell and colleagues 13 reported that BED patients who had an onset of binge eating prior to dieting had signi cantly higher lifetime rates of substance use disorders. No other current or lifetime psychiatric disorders or the presence=absence of any personality disorder differed signi cantly between BED patients who binge or dieted rst. Spurrell and colleagues, 13 however, did note nonsigni cant trends for the binge rst group to have higher rates of current substance abuse and personality disorders. We note several potential limitations. Our study group was recruited for clinical trials; thus, the ndings may not be generalizable to general outpatient or community populations, or to BED individuals who self-select to weight control rather than eating disorder programs. It is possible that such persons may have different histories and variations in the development and presenting manifestations of BED. Moreover, we note our reliance on retrospective recall of age and sequence of diet and binge eating on both self-report and interview assessments. Retrospective recall may be inaccurate or in uenced by systematic biases. We also relied on participants' de nitions of diets, which can vary across people. Longitudinal prospective studies are needed to determine developmental pathways. 41 In conclusion, a substantial subgroup of BED patients (roughly one-third) report that binge eating preceded their rst diet. This nding, which replicates previous reports for BED, and appears higher than that generally reported for bulimia nervosa, may have implications for etiologic models of binge eating. Further research, particularly multivariate 43 and longitudinal 40,41 work, is needed to understand the nature and signi cance of the possible differences in developmental pathways to BED. Acknowledgement This work was supported by NIH grant DK49587 (Dr. Grilo). 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