An interesting study on psychology of binge eating disorder.
read a neat article about behavior 'extinction' and it's effects on dieting at http://youarenotsosmart.com/2010/07/07/extinction-burst/
Basically, as you try to quit doing something that has been positively reenforced with a reward, your desire to get that reward will go way up if you can't get it. Sounds pretty simple, right?
So I wanted to do a little bit more research on this, and came across this study:
"Evaluation of Extinction as a Functional Treatment for Binge Eating"
(Published in the journal Behavior Modification, 2008 issue 32, url http://bmo.sagepub.com/content/32/4/556)
It looks like you need to pay to read it OR have access through a university, so I'm just going to post up the interesting bits.
Binge eating is a serious behavior problem exhibited by individuals diagnosed with binge eating disorder and bulimia nervosa. Binge eating is thought to be maintained by automatic negative reinforcement in the form of relief from negative emotional responding. Current treatments produce only moderate abstinence, perhaps because they do not attempt to alter the functional consequences of the behavior. Although extinction has been thought impossible with behaviors maintained by automatic negative reinforcement, this study evaluated the application of extinction with binge eating.
Four women who reported engaging in binge eating at least twice per week participated. Participants listened to an audio tape recording of the covert verbal behavior associated with their negative emotional responding during the binge to prevent alleviation of the negative emotional responding,thus eliminating the reinforcer in an attempt to reduce the behavior. (So, essentially, this is to make bingeing not rewarding anymore, as far as I can tell.) The procedure effectively reduced frequency of the binges when correctly implemented. Implications and suggestions for future research are discussed.
A substantial amount of research has identified negative emotional responding as an antecedent to binge eating (e.g.,Abraham & Beumont,1982; Arnow, Kenardy, & Agras, 1992; Grilo, Shiffman, & Carter-Campbell, 1994; Heatherton & Baumeister, 1991; Lee & Miltenberger, 1997; Loro & Orleans, 1981; McManus & Waller, 1995; Mizes, 1985; Polivy & Herman, 1993; Schlundt, Johnson, & Jarrell, 1996; Williamson, White, York-Crowe, & Stewart, 2004).
In addition, research has shown that binge eating provides relief from negative emotions,at least temporarily (e.g.,Abraham & Beumont, 1982; Arnow et al., 1992; Loro & Orleans, 1981; McManus & Waller, 1995; Miltenberger, 2005; Mizes, 1985; Polivy & Herman, 1993; Redlin, Miltenberger, Crosby, Wolff, & Stickney, 2001; Stickney & Miltenberger, 1998; Stickney, Miltenberger, & Wolff, 1999; Williamson et al., 2004). It has been noted that the change in negative emotions during binge eating plays a vital role in the maintenance of binge eating. Various researchers have suggested that binge eating shifts attention from negative thinking and emotional responding to eating, and the shift in attention reduces emotional responding, thus reinforcing the behavior of binge eating. (Heatherton & Baumeister, 1991; McManus & Waller, 1995; Williamson et al., 2004). Polivy and Herman (1993) note that, although binge eating may have serious long-term negative consequences such as weight gain or other health problems,the immediate attenuation of negative emotions maintains the behavior.
In behavior analytic terms,binge eating is automatically negatively reinforced because it provides momentary relief from aversive emotional responding (Miltenberger, 2005). Negative emotions function as an establishing operation (EO) that makes the reinforcer (relief from the negative emotions) more powerful within the negative reinforcement contingency (Iwata & Worsdell, 2005). Other antecedents, such as being alone, having high-calorie foods present, being at home, or having unstructured time, are discriminative stimuli (S D) for binge eating as binge eating has previously been reinforced in the presence of these antecedents (Miltenberger, 2005). When the S Ds and EO occur concurrently,binge eating becomes most probable (Miltenberger, 2005).
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Current interventions do not eliminate the reinforcing consequence for the behavior (McManus & Waller,1995; Polivy et al.,2005), and thus when binge eating occurs, it continues to be reinforced. Considering effectiveness of extinction, a procedure that eliminates the reinforcer for a behavior, as a functional treatment for other problem behaviors (Lerman & Iwata, 1996), an evaluation of extinction seems warranted. Extinction has been shown to be effective in decreasing undesirable behaviors maintained by three forms of reinforcement:social positive reinforcement,social negative reinforcement,and automatic positive reinforcement (Iwata, Pace, Cowdery, & Miltenberger, 1994; Iwata, Vollmer, Zarcone, & Rodgers, 1993; Iwata & Worsdell, 2005). However, extinction has never been used with binge eating or other problem behaviors maintained by automatic negative reinforcement. In fact,many researchers argue that extinction cannot be utilized for automatic negative reinforcement because it would require the continuation of an aversive internal event as the behavior occurred (Iwata et al., 1993; Iwata & Worsdell, 2005; Miltenberger, 2005).
Theoretically, it would be impossible for a therapist to manipulate an internal event, thus making it impossible to guarantee that the event was not terminated contingent on the behavior (Iwata et al., 1993; Iwata, Vollmer, & Zarcone, 1990; Iwata & Worsdell, 2005; Miltenberger, 2005). In addition, researchers have argued that prolonging an aversive event,even to decrease an inappropriate behavior, could be unethical (Iwata et al., 1993; Iwata & Worsdell, 2005; Lee & Miltenberger, 1997).
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Method Participants and Setting
Participants were four women who met the DSM-IV-R diagnostic criteria for bulimia or BED based on their responses to the Questionnaire for Eating Disorders Diagnosis (Q-EDD; Mintz, O’Halloran, Mulholland, & Schneider,1997). In addition to engaging in binge eating twice a week, participants must have revealed through interviews and self-report measures information to suggest that their binge eating produced relief from negative emotional responding (automatic negative reinforcement). Participants were excluded if they engaged in any substance abuse other than occasional alcohol use or if their binge eating behavior did not appear to be reinforced by relief from negative emotional responding. This study was approved by the university Institutional Review Board, and informed consent was obtained from all participants.
Joann (all names are pseudonyms) was a 54-year-old Caucasian female with a body mass index (BMI) of 44 (morbidly obese) who was recruited through a local eating disorders clinic.In addition,Joann endorsed experiencing a reduction in these emotions during a binge on the Conditions Associated with Binge Eating scale (CABE; to be described later).
Eve was a 21-year-old Caucasian female with a BMI of 23 (normal weight) who was recruited from an e-mail sent to all students at a local university. According to the Q-EDD,Eve met diagnostic criteria for BN,purging type. Eve had previously been diagnosed with and treated for BN. Treatment was initially effective but Eve’s symptoms reappeared after a period of time without treatment. Eve first began binge eating in third grade and reported binge eating four or five times a week prior to the study. Eve said she was most likely to binge eat when she was at home in the evenings, alone. Eve indicated usually feeling stressed out,frustrated,or bored before binge eating and reported feeling better while binge eating. Eve described feeling guilty after binge eating and admitted to engaging in self-induced vomiting. Eve reported on the EES feeling an overwhelming urge to eat while experiencing a number of emotions,namely discouraged,inadequate, blue,sad,frustrated,lonely,guilty,bored,and helpless. Eve described experiencing a decrease in most of these emotions while binge eating, with the exception of feeling guilty, which increased during binge eating.
Tabitha was a 49-year-old Caucasian female with a BMI of 37 (moderately obese) who was recruited through an e-mail sent to all students at a local university. According to the Q-EDD, Tabitha met diagnostic criteria for BED; however,she had never been diagnosed,nor had she sought treatment. Tabitha began binge eating when she was 22 and reported binge eating three to five times a week prior to the study. Tabitha was most likely to binge eat at work; in the afternoon; and when angry, bored, or nervous. Tabitha reported experiencing a decrease in negative emotions while binge eating, but experienced regret and guilt after binge eating. On the EES, Tabitha reported feeling an overwhelming desire to eat in response to the following emotions: inadequacy, irritation, worry, frustration, furiousness, anger, guilt, and upset. Despite reporting experiencing a decrease in negative emotions while binge eating in the interview, Tabitha did not endorse any reductions in emotions on the CABE.
Kathryn, a 45-year-old Caucasian female with a BMI of 39 (moderately obese), was recruited through an e-mail sent to all students at a local university. According to the Q-EDD,Kathryn met diagnostic criteria for BED. Kathryn had previously received treatment at a local eating disorders unit and had found it helpful but could not continue because of lack of insurance coverage. Kathryn began binge eating when she was in seventh grade and reported binge eating three times a week prior to the study. Kathryn was most likely to binge eat in the evening, in her bedroom, while alone, and when upset. Kathryn reported escaping from negative covert verbal behavior while binge eating. Kathryn indicated on the EES feeling an overwhelming urge to eat when feeling blue, lonely, furious, nervous, angry, guilty, and upset. Kathryn also reported experiencing a decrease in all negative emotions listed on the CABE both during and after binge eating. Sessions were conducted in a research room in the Department of Psychology at a local university. Data collection occurred in the participants’natural environments.
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Target Behavior
A binge eating episode was defined as the consumption of more than 500 calories while the participant reported feeling out of control. Rossiter and Agras (1990), in an empirical test of the definition of a binge, found that 75% of binges consisted of more than 500 calories for a sample of 32 bulimics; therefore, 500 calories was chosen as the minimum intake of a binge.
32 is a REALLY small sample size for determining this, but it's kind of an arbitrary term anyway. There's never a singular 'binge thresh hold' for drugs and alcohol either, it's relative to the individuals and circumstances.
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Individuals who were referred or who responded to an e-mailed advertisement were contacted via telephone or e-mail and asked if they would like to participate in a study evaluating the effects of a new treatment for binge eating. Interested individuals who qualified were scheduled for the initial interview that was conducted in person. At the initial interview, procedures of the study and rationale for the treatment were explained in full to the participant and consent was obtained. Individuals, who indicated that they were interested in and in need of a more intense course of treatment, were referred to a local eating disorders clinic. After consent was obtained, the participant was asked to complete the Q-EDD,the EES,and the CABE. The researcher then conducted the BEI with the participant and assessed whether automatic negative reinforcement was the likely maintaining consequence of the participant’s binge eating.
If the participant’s binge eating behavior appeared to be maintained by another form of reinforcement,the participant was provided with a referral to a local eating disorders clinic and dismissed from the study. No individuals were dismissed for this reason. If the participant’s binge eating appeared to be maintained by automatic negative reinforcement, the participant was accepted into the study and educated on the use of the self-monitoring form. This education included instruction for completing the form and guidance on portion size estimation. In addition, the researcher and participant discussed the participant’s experience of negative emotions and assessed the covert verbal behavior associated with those states.
The participant was coached to express negative covert verbal behavior (negative self-talk) overtly in session and practiced recording on the tape recorder. Once the participant had demonstrated proficiency at expressing and recording the negative self-talk, she was instructed to use the tape recorder to record her negative self-talk when negative emotions occurred throughout the week. Once the participants had sufficiently demonstrated the skills required for self-monitoring and recording,they were provided with a packet containing a week’s worth of forms and a tape recorder.
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Treatment.
In the initial treatment session, the researcher provided a rationale for the treatment procedure. The researcher first explained to the participant (in everyday language) that her binge eating was maintained by relief from negative emotions. The researcher then explained what extinction is and how the researcher intended to implement it with the participant. Once the rationale had been provided to the participant,the participant was instructed to begin playing the tape of her negative self-talk throughout every binge. The participant was instructed to set the volume to a decibel higher than any surrounding noise,a decibel level that could be heard clearly over any chewing or food wrapper sounds. If the participant binge ate in public or in a situation where someone else could hear the tape, the participant was provided with a headset to wear. The participants were educated about the importance of consistent and accurate use of the procedure. Once the rationale, instruction, and education were concluded, the participant was given a looped tape of their negative self-talk and a headset if needed. The looped tapes were approximately 30 minutes in length, and the individual segments on the loop ranged in length from 6 to 12 minutes, depending on the duration of verbal behavior recorded for each participant. Participants continued to take self-monitoring data and recorded whether the procedure was used during each binge. Weekly meetings continued to discuss the data and to ensure that the procedure was being implemented correctly. Phone calls were made if it was necessary to remind the participants to use the procedure when they binge ate,based on the participant’s reporting of treatment integrity at the last session. In the final session, the participant was asked to complete the CABE for assessment of the emotional states related to the binge eating with the treatment procedure in place. The participant also completed the Acceptability Questionnaire. Finally, referrals were given for any eating or mood disorder symptoms that persisted.
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Discussion
Overall, results of the study indicated that utilizing extinction for binge eating maintained by automatic negative reinforcement in the form of relief from negative emotions was effective in reducing the frequency of binge eating for all four participants,with total cessation of binge eating for three of the participants. The rapid reductions in binge eating for all participants suggest that this procedure may be both effective and efficient. Relative to research on CBT for binge eating in which treatment is implemented over a substantial number of weeks (Leitenberg, 1995; Pull, 2004; Stein et al., 2001),the intervention in this study produced a relatively immediate effect.
All participants said they were less motivated to binge eat because they knew they would have to listen to the tape of their own negative self-talk. In addition, all participants reported terminating eating episodes earlier than they would have in baseline (and thus avoided binge eating) because they felt upset or uncomfortable while listening to the tape. Because this is the first evaluation of extinction with a behavior maintained by automatic negative reinforcement, direct and systematic replications are needed to establish the effectiveness and generality of the procedure.
Although the treatment procedure was effective for all participants, it is unclear why the procedure worked. The procedure was intended to function as extinction (negative emotions were not terminated contingent on binge eating). However, it is possible that instead it functioned as positive punishment (aversive emotional responding was added contingent on binge eating). Participants indicated that there were times that they did not binge eat because they did not want to listen to the tape. This finding would suggest that listening to the tape was aversive. However, it is still not clear whether listening to the tape continued an aversive stimulus or added (or increased the intensity of) an aversive stimulus.
In an attempt to resolve this issue,the participants were asked if listening to the tape at the time binge eating was about to occur made them feel worse than before listening to the tape (punishment), or if listening to the tape just did not let them feel better (extinction).
Although all four participants acknowledged that the tape did not allow them to feel better, which supported the extinction hypothesis, two of the four participants reported that the tape did make their preceding emotions worse, which supported the punishment hypothesis. Future research should examine whether this procedure functions as extinction or punishment. Results of the CABE demonstrated the change in negative emotions that likely maintained binge eating. The preintervention negative change scores from “before” to “during” binge eating showed that these emotions decreased substantially during the binge in baseline, thus reflecting an automatic negative reinforcement function of binge eating. In addition, by examining the change scores, it was observed that, postintervention, binge eating no longer attenuated negative emotional responding.
The results showed that the scores for the negative emotional responding no longer decreased from “before”to “during”the binge or decreased less during treatment than in baseline. In addition, some scores increased from “before”to “during”the binge, which represented an increase in the intensity of the emotion during the binge while listening to the taped covert verbal behavior. These results supported the contention that the intervention was effective in eliminating the reinforcer for binge eating, but also supported the idea that listening to the taped verbal behavior may have been a form of positive punishment. Several emotional variables increased during the binge while the participants listened to the tape; if these scores represented aversive stimulation, then this would indicate that aversive stimulation had been added and implicate positive punishment as a potential process decreasing the frequency of binge eating.
Of interest, all participants reported that listening to the tape recording of their negative self-talk made them think about why they binge eat and helped them develop awareness of the factors contributing to their own behavior. This finding may have implications for increased acceptability of extinction or other functional interventions.
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One possible explanation of this effect is the cyclical nature of emotions associated with a binge. Typically, intense negative emotions were experienced before a binge, decreased during the binge, and then reemerged after the binge, often at the same intensity felt before or at a greater intensity. This reemergence of the negative emotions likely served as an EO for the next binge. Considering this cycle, it is possible that because the participants were no longer bingeing frequently and were thus no longer consistently perpetuating the emotional cycle, the intensity of the negative emotions decreased overall. One other explanation for the decrease observedis that the participants’overall levels of negative emotions were improved subsequent to treatment as a result of successfully decreasing their binge eating. Anecdotally, several of the participants reported feeling successful when their frequency of binges decreased from the previous week. Perhaps successfully decreasing a behavior that they view as unacceptable increased the participants’experience of positive emotion and thus decreased the negative emotions overall. Future research should examine whether emotional responding improves overall as a result of the treatment procedure.
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One issue raised in the introduction is that the use of extinction that involves prolonging an aversive stimulus may be unethical. Although this may be the case with physically painful or damaging stimuli, extinction in this study did not prolong exposure to physically painful or damaging stimuli. The stimulation that was prolonged involved exposure to negative emotions. The participants all agreed to the procedure after it was thoroughly described to them,continued to use the procedure as instructed even though they could have terminated participation at any time, and rated it as helpful at the end of the study. Therefore,it appeared that there was no ethical problem with the use of extinction in this study. Future research should include a social validity measure to further assess the participants’reactions to the use of the procedure.
In addition to examining the areas discussed above, future research may benefit from implementing this procedure in a laboratory setting. Utilizing a laboratory setting would provide a controlled environment to ensure that the procedure was being implemented every time and would remove the possible confound of inconsistency and intermittent reinforcement.
Eve’s data depict the difficulty with consistency in the implementation of the treatment. Eve said that she might have difficulty utilizing the procedure because she often binged in public and would likely draw attention to herself while wearing the headphones and listening to the audiotape. Although she was encouraged to be as consistent as possible,during the first 3 weeks of treatment (and especially in the 3rd week),she was inconsistent with her use of the procedure. A clear pattern developed in the data; when Eve used the procedure, she stopped eating within a short period of time, thus preventing a binge. When Eve did not use the procedure, she continued to engage in binge eating. In an effort to increase her compliance with the procedure,the intermittent reinforcement of binge eating created by the inconsistent use of the procedure was explained to Eve in everyday language. She then utilized the procedure more consistently in the following weeks,and a decrease in binge eating was subsequently observed in the data. In addition to increasing consistency,a laboratory evaluation would afford enough control to examine the function of this procedure, to tease apart extinction effects from punishment effects.
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In summary, results of this study suggest that extinction of binge eating maintained by automatic negative reinforcement may be effective in reducing the behavior. One limitation of this study was the reliance on self-report assessments and self-monitoring data. Unfortunately, the private nature of the behavior does not lend itself to functional analysis methodologies and traditional data collection. Future research should examine ways to set up analogue conditions to directly observe the behavior as possible controlling variables are manipulated. Although more research must be conducted to replicate and extend the findings and to investigate the mechanisms responsible for the observed effects, the use of extinction as described here may be a promising intervention for binge eating.
I can post up the whole thing if somebody wants it, but the rest is pretty much just the statistical analysis of effectiveness and what not. The idea of a "extinction burst," from that first article, really caught my attention. That seems like what bingeing is, through and through, you know? I don't think operant conditioning can work magic or anything, but it's an appealing methodology for dealing with behavior that makes a person feel out of control (there's lots of stuff out there on smoking, alcohol, etc, as well).
What do you guys think about it?