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. Author manuscript; available in PMC: 2024 Jun 1.
Published in final edited form as: Int J Eat Disord. 2023 Mar 15;56(6):1199–1206. doi: 10.1002/eat.23929

Loss of Control in Binge-Eating Disorder: Fear and Resignation

Hayley Perelman 1,2, Kelsey Gilbert 1,3, Carlos M Grilo 1, Janet A Lydecker 1
PMCID: PMC10247475  NIHMSID: NIHMS1880885  PMID: 36920120

Abstract

Objective:

Binge-eating disorder involves overeating while feeling of loss of control (LOC). Emotions around LOC appear to vary; some patients fear LOC whereas others feel powerless or “resigned” to LOC. This study examined differences in psychopathology among treatment-seeking patients with binge-eating disorder categorized with fear of LOC, resignation to LOC, and no fear/resignation of LOC.

Method:

Doctoral research clinicians administered diagnostic and semi-structured interviews to characterize psychopathology and establish a diagnosis of binge-eating disorder in participants (N=382). The interview assessed fear of LOC in the past month. Further queries assessed whether, in the absence of fear of LOC, patients were resigned to LOC or had no fear/resignation.

Results:

Patients with fear of LOC and resigned to LOC endorsed significantly greater global eating-disorder psychopathology than patients with no fear/resignation. Patients with fear of LOC reported greater distress about binge eating and greater depression than those with no fear/resignation. Patients resigned to LOC reported significantly more frequent binge-eating episodes than those with fear of LOC and no fear/resignation. Black individuals and men were more likely to report no fear/resignation than other demographic groups.

Discussion:

This study describes a novel clinical aspect of binge-eating disorder: resignation to LOC. Findings highlight the importance of including anticipatory cognitive-affective experiences in treatment formulations and planning. Future research should examine co-occurrence of these experiences and their association with impairment. Future research should also examine how fear of LOC and resignation to LOC change during treatment and whether they predict or moderate treatment outcomes.

Keywords: binge-eating disorder, eating behavior, fear, loss of control, depression, body image

Introduction

Binge-eating disorder is a prevalent and serious public health problem (Udo & Grilo, 2018, 2019) that involves eating an objectively large amount of food while experiencing a sense of loss of control (i.e., a binge) and experiencing distress about the binge eating, without the accompanying compensatory behaviors that characterize bulimia nervosa (American Psychiatric Association, 2013). There is considerable heterogeneity in the clinical presentation of individuals with binge-eating disorder; for example, some individuals with binge-eating disorder endorse overvaluation of their shape and weight (Grilo, 2013; Grilo, White, Gueorguieva, Wilson, et al., 2013), secretive eating (Lydecker & Grilo, 2019), body checking and avoidance behaviors (Reas et al., 2005), and feelings of guilt and shame (Craven & Fekete, 2019; Zeeck et al., 2011). Loss of control (LOC) is a hallmark feature of binge-eating disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) and the International Classification of Diseases (ICD-11; World Health Organization, 2019/2021). The ICD-11 prioritized LOC as the core diagnostic feature of binge-eating disorder even in the absence of the “objectively large” size component of an eating episode (Stein et al., 2020; World Health Organization, 2019/2021). However, how patients with BED feel when thinking about or anticipating LOC has not received much empirical attention to date.

In the assessment of eating-disorder psychopathology among individuals with binge-eating disorder, thoughts and affect preceding and following binge episodes can inform treatment formulations. Some patients experience an anticipatory fear of LOC. In a study tracking emotions before and after eating episodes, individuals with lifetime binge-eating disorder reported greater fear of LOC before an eating episode compared to those who never had binge-eating disorder (Mason et al., 2018). Additionally, fear of LOC was associated significantly with global eating-disorder psychopathology (Mason et al., 2018). However, other anticipatory cognitive-affective experiences related to binge eating have not been characterized. Fear of LOC may drive efforts to avoid eating and engage in restriction (Rand-Giovannetti et al., 2020; Ricca et al., 2012). Among adolescents, those endorsing LOC were more likely to skip eating lunch and evening meals and eat snacks in between meals (Matheson et al., 2012). Restriction is part of the hypothesized mechanisms that maintain binge eating, which means that skipping meals out of fear of LOC may lead to more severe binge-eating psychopathology. It is not known, however, whether adults’ daily eating patterns differ by whether they feel anticipatory fear of LOC or the related feeling of being resigned to LOC occurring.

Individuals with eating-disorder psychopathology report feeling as though their eating disorder forces them to behave in ways they otherwise would not choose to behave (Mullen et al., 2020). People with eating disorders can experience a sense of powerlessness (i.e., feeling resigned to the eating disorder) regarding LOC and their eating behaviors (Mullen et al., 2020). This powerlessness has been associated with over-control (such as restriction) and negative affect, yet the sense of feeling resigned is not traditionally assessed as it relates to fear of LOC (Mullen et al., 2020). The lack of powerlessness and fear of LOC is in contrast to recent findings highlighting that fear and eating-disorder psychopathology have important clinical associations (Levinson & Williams, 2020). For example, many individuals with eating disorders endorse fear of gaining weight, fear of specific foods, and fear of judgment by others (Brown & Levinson, 2022; Levinson & Williams, 2020). The limited work conducted on race, ethnicity and fear of LOC suggests that men may report less fear than other genders (Carey et al., 2017), and Hispanic/Latinx individuals may report more fear than other racial/ethnic groups (Bennett & Dodge, 2007). In the current study, we assessed whether, if participants denied feeling fear of LOC, they felt resigned to LOC, as though they could not prevent the binge-eating episode from occurring. The resigned feeling reflects how patients describe the experience of LOC eating (Roberto et al., 2016), but has not been examined as an anticipatory feeling parallel to fear of LOC.

When a person is resigned to an outcome that they do not believe they can successfully manage, they may also experience negative emotions including helplessness, negative affect, depression, and low self-esteem (Riva et al., 2017; Williams, 2009). In a longitudinal study, fear of LOC was prospectively associated with higher reported depressive symptoms seven years later (Hazzard et al., 2019). Additionally, higher negative affect prospectively predicted LOC eating in short-term ecological momentary assessment studies (Felonis et al., 2021). It is plausible that patients who endorse feeling resigned to LOC may also experience symptoms of negative affect and low self-esteem, and that feeling resigned to LOC may be associated with eating-disorder psychopathology, but this has not been examined.

The current study assessed treatment-seeking patients with binge-eating disorder to characterize their anticipatory experiences as fear of LOC, resigned to LOC, or no fear/resignation. Patients with fear of LOC, resigned to LOC, and with no fear/resignation were compared on: 1) demographic characteristics, including gender and race; 2) eating-disorder psychopathology, binge-eating episode frequency, distress about binge eating, and binge-eating disorder age of onset; 3) depression scores; and 4) total meals consumed and total snacks consumed in the past month. We compared demographic characteristics based on prior work on race, gender, and binge eating (Bennett & Dodge, 2007; Carey et al., 2017; Hazzard et al., 2019), and we hypothesized that men and individuals identifying as Black would have lower proportions categorized in the fear of LOC study group. We chose to examine global eating-disorder severity based on previous research that indicated an association of fear of LOC and eating-disorder psychopathology (Mason et al., 2018; Ricca et al., 2012), and we hypothesized that: patients with fear of LOC and resigned to LOC would experience greater binge-eating episode frequency and greater overall eating-disorder psychopathology than patients without fear/resignation. Based on prior literature showing an association between feelings of fear, resignation and negative affect (Brown & Levinson, 2022; Felonis et al., 2021; Hazzard et al., 2019; Levinson & Williams, 2020; Riva et al., 2017; Williams, 2009), we chose to examine depression scores, hypothesizing that patients who experienced resigned LOC would experience greater depressive symptoms than those without fear of LOC. Finally, based on the literature that demonstrated an association between fear of LOC and restriction (Rand-Giovannetti et al., 2020; Ricca et al., 2012), and between LOC and eating fewer meals and more snacks (Matheson et al., 2012), we examined how many meals and snacks patients reported consuming in the past month, hypothesizing that treatment-seeking adults with binge-eating disorder who reported fear of LOC and resigned LOC would report fewer total meals, and more total snacks, compared to those with no fear/resignation of LOC.

Methods

Procedures

Data from the current study came from a dataset of aggregated binge-eating disorder treatment studies. Treatment studies were advertised as pharmacological and psychological treatment studies for binge-eating disorder (Grilo, 2017; Grilo, Masheb, & Salant, 2005; Grilo et al., 2014; Grilo, Masheb, & Wilson, 2005; Grilo et al., 2011; Grilo, White, Gueorguieva, Barnes, et al., 2013). All data were collected as part of baseline assessments. All studies used consistent recruitment strategies, inclusion criteria, and assessment protocols, and were conducted at one location. Studies took place at an urban, medical-school-based specialist program in the northeastern region of the United States. All participants were evaluated using a consistent, interview-based assessment of the binge-eating disorder diagnosis and associated eating disorder variables, including binge-eating episodes as well as fear of LOC.

All studies received ethical approval from the Yale Human Investigations Committee; all participants provided written informed consent prior to study assessments.

Participants

Participants (N=382) were between 18 and 65 years old and met DSM-IV research criteria for binge-eating disorder (American Psychiatric Association, 2000). Participants were excluded if they had a severe mental illness that could interfere with the study procedures (e.g., psychosis), had medical conditions that influenced weight or eating, were receiving outside treatment for weight or eating disorders, were taking medications that could influence weight or appetite, or were pregnant.

Participants reported they were women (n=259; 71.5%) or men (n=103, 28.5%). Participants identified as White (n=231, 64.0%), Black (n=75, 20.8%), Hispanic (n=33, 9.1%) or a race/ethnicity that was not listed (n=22, 6.1%). Overall, participants had a mean age of 46.7 (SD=10.4; range 18 to 65 years) and a mean BMI of 39.0 kg/m2 (SD=5.9; range 28.6 to 56.0 kg/m2). Participants had varying levels of education: high school or less than high school (n=81, 22.5%), some college (n=124, 34.4%), or a college degree or more (n=155, 43.1%).

Measures

Research clinicians, who were doctoral-level, were trained and monitored to maintain reliability. Research clinicians administered the Structured Clinical Interview for DSM-IV Axis I Disorders (First et al., 1997) to establish binge-eating disorder diagnosis and age of onset. They also conducted the semi-structured Eating Disorder Examination interview (Fairburn & Cooper, 1993) to confirm binge-eating disorder diagnosis and to evaluate eating disorder psychopathology. Research clinicians measured height and weight of participants and calculated body mass index (BMI; kg/m2).

Eating Disorder Examination (EDE)

The EDE (Fairburn & Cooper, 1993) is a well-established, semi-structured, investigator-based interview that can be used by clinicians to assess eating disorders. The EDE has good inter-rater and test-retest reliability in binge-eating disorder (Grilo et al., 2004). The EDE yields a total score of global eating-disorder severity, which includes items related to dietary restraint, eating concern, weight concern, and shape concern; in the current study, this global score was internally consistent (α=.83), with excellent inter-rater reliability (intraclass correlation coefficients .78 to .94). The EDE assesses eating-disorder psychopathology in the past 28 days, and over longer intervals corresponding to diagnostic criteria. The EDE assesses the frequency of objective binge-eating episodes (OBEs), which are defined as eating an unusually large amount of food while perceiving LOC over eating, and assesses distress related to binge eating. The EDE also assesses the “pattern of eating” typical meals and snacks.

The standard EDE includes the “Fear of Losing Control Over Eating” item (“Over the past four weeks have you been afraid of losing control over eating?”) prior to the assessment of binge-eating episodes, which is scored by the number of days fear of LOC was experienced (0=0 days, 1=1–5 days, 2=5–12 days, 3=13–15 days, 4=16–22 days, 5=23–27 days, 6=everyday) (Fairburn & Cooper, 1993). When participants denied fear of LOC, we added the additional probe, “is this because you were resolved that you were going to have a binge episode?”. Based on this response, participants were categorized as endorsing fear of LOC, resignation to LOC, or no fear/resignation of LOC, and categories did not overlap. The frequency rating for this item was included for those endorsing fear of LOC or resignation to LOC.

Beck Depression Inventory (BDI)

The BDI is a widely-used measure of depression (Beck & Steer, 1987). It has excellent psychometric properties (Beck et al., 1988) and captures a broad range of negative affect. In the current study, internal consistency was excellent, α=.89.

Statistical Analyses

To evaluate differences between participants reporting (1) fear of LOC, (2) resignation to LOC, and (3) no fear/resignation, chi-square tests (categorical variables) and analyses of variance (ANOVAs; continuous variables) compared groups. A non-parametric test, the independent-samples Kruskal-Wallis test, was used for OBE episodes due to non-normality. ANOVAs met the assumption of homogeneity of variance. Partial eta-squared (ηp2) was calculated for ANOVAs as an effect size. Partial eta squared (ηp2) values are considered small at .01, medium at .06, and large at .14 (Cohen, 1988). Post-hoc pairwise comparisons used a Scheffé correction for multiple comparisons.

Results

Of the 382 participants with BED, 60.2% reported fear of LOC (n=230), 27.5% reported resignation to LOC (n=105), and 12.3% denied feeling both fear of LOC and resignation to LOC (n=47).

Table 1 summarizes demographic characteristics of participants in each study group as well as differences between groups. The fear of LOC group had a higher proportion of patients with a high school education than other education levels, whereas the resignation to LOC group had more people with some college or a college degree, and the no fear/resignation group had a higher proportion of people with a partial college education. A significantly greater proportion of men than women reported no fear/resignation. Resignation to LOC and fear of LOC did not differ by gender. Individuals who identified as Black were more likely to report no fear/resignation than other anticipatory cognitive-affective experiences. Study groups did not differ significantly in participants’ age.

Table 1.

Demographic characteristics of the full sample and study groups

All BED (N=382) Fear LOC (n=230) Resigned LOC (n=105) No Fear LOC (n=47) χ2 df p ϕ Group differencesa
Education, n (%) 17.46 4 .002 .220
 HS or less 81 (22.5%) 63 (28.9%) 13 (13.3%) 5 (11.4%) Fear>Resigned,No
 Some college 124 (34.4%) 64 (29.4%) 37 (37.8%) 23 (52.3%) Fear<No
 College or more 155 (43.1%) 91 (41.7%) 48 (49%) 16 (36.4%) -
Race/Ethnicity, n (%) 8.76 6 .19 .156
 Black 75 (20.8%) 39 (17.8%) 22 (22.4%) 14 (31.8%) Fear<No
 Hispanic/Latinx 33 (9.1%) 25 (11.4%) 6 (6.1%) 2 (4.5%) -
 White 231 (64.0%) 139 (63.5%) 65 (66.3%) 27 (61.4%) -
 Other 22 (6.1%) 16 (7.3%) 5 (5.1%) 1 (2.3%) -
Sex/Gender, n (%) 5.43 2 .07 .122
 Men 103 (28.5%) 57 (25.9%) 27 (27.6%) 19 (43.2%) Fear<No
 Women 259 (71.5%) 163 (74.1%) 71 (72.4%) 25 (56.8%) Fear>No
Age, M (SD) 46.68 (10.4) 46.25 (10.76) 47.07 (10.03) 47.93 (9.08) 0.58b 2, 359 .56 .003c -
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Note. Omitted groups in “group differences” column were not significantly different from any other group. Phi (ϕ) values are considered small at .1, medium at .3, and large at .5. LOC, Loss of Control

a

Significant pairwise comparison at p<.05.

b

ANOVA F test.

c

Effect size partial eta squared (ηp2). Partial eta squared (ηp2) values are considered small at .01, medium at .06, and large at .14.

Table 2 summarizes baseline clinical characteristics of treatment-seeking patients with binge-eating disorder within and across study groups. ANOVAs (continuous variables), Kruskal-Wallis test (non-normally distributed continuous variable), and chi-square tests (categorial variables) examined differences between groups. OBE frequency differed significantly by group (H3=4.02, p=.032). Patients resigned to LOC had more OBEs than patients with fear of LOC (p=.03) and those with no fear/resignation (p=.02). Participants with fear of LOC experienced greater distress about binge eating than those with no fear/resignation of LOC (p=.004). However, study groups did not differ significantly on age of binge-eating disorder onset (F2,378=2.40, p=.09, ηp2=.013). Body mass index did not differ significantly by group (F2,378=1.18, p=.31, ηp2=.006).

Table 2.

Analyses of variance comparing clinical characteristics by study group

All BED Fear of LOC Resigned to LOC No Fear/Resignation
(n=382) (n=230) (n=105) (n=47)
M (SD) M (SD) M (SD) M (SD) F df p ηp2 Group differencesb
OBE episodesa 20.20 (15.44) 19.48 (14.34) 23.39 (18.35) 16.57 (12.29) 6.91 2 .03 n/a Resigned>No, Fear
Binge Eating Distress 3.84 (0.94) 3.97 (0.89) 3.71 (0.92) 3.47 (1.10) 7.05 2,378 <.001 .036 Fear>No
Age of BED onset 22.13 (13.05 22.02 (13.20) 20.65 (12.06) 25.68 (13.95) 2.40 2,363 .09 .013 -
EDE Global 2.66 (0.91) 2.84 (0.86) 2.58 (0.87) 1.96 (0.88) 20.82 2,379 <.001 .099 Fear>Resigned>No
BMI 38.96 (5.91) 39.01 (6.00) 39.38 (5.61) 37.80 (6.13) 1.18 2,378 .31 .006 -
BDI Depression 15.40 (9.36) 16.75 (9.09) 14.40 (10.04) 10.85 (7.32) 8.38 2,360 <.001 .044 Fear>No
Total Meals 68.53 (14.64) 68.62 (14.30) 68.90 (15.40) 67.28 (14.75) 0.21 2,378 .81 .001 -
Total Snacks 52.85 (20.17) 54.58 (19.40) 53.03 (21.22) 44.02 (19.59) 5.47 2,378 .005 .028 Fear,Resigned>No
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Note. BED, Binge-Eating Disorder; LOC, Loss of Control; EDE, Eating Disorder Examination; OBE, Objective Binge Episode; BDI, Beck Depression Inventory. Episodes and meals are the frequency in the past 28 days. EDE global score is the average eating-disorder psychopathology severity in the past 28 days. ηp2 = partial eta squared, effect size for ANOVAs. Per Cohen (1988), partial eta squared (ηp2) values are considered small at .01, medium at .06, and large at .14.

a

Non-parametric Independent-Samples Kruskal-Wallis Test

b

Significant at p<.05.

Global eating-disorder severity differed significantly by group (F2,379=20.82, p<.001, ηp2=.099) and all pairwise comparisons were significant. Findings showed a graded relationship: global severity was significantly higher among participants with fear of LOC than those resigned to LOC (p=.04), which was in turn significantly higher than those with no fear/resignation (p<.001). Depression scores on the BDI differed significantly by group (F2,360=8.38, p<.001, ηp2=.044). Participants with fear of LOC had significantly higher depression scores than those with no fear/resignation (p<.001).

Total meals did not differ significantly by group (F2,378=0.21, p=.81, ηp2=.001). However, total snacks consumed differed significantly by group (F2,378=5.47, p=.005, ηp2=.028) such that participants with fear of LOC and those resigned to LOC reported eating significantly more snacks than those with no fear/resignation (p=.01 and p=.04), although fear and resignation of LOC did not differ significantly from each other.

Discussion

LOC while overeating is a key aspect of binge-eating disorder, but individuals who have experienced LOC may have a range of anticipatory cognitive-affective experiences about future LOC. While fear of LOC has received some empirical attention, this is the first study, to our knowledge, to examine an alternative to fear of LOC, specifically feeling resigned to LOC eating. Our hypothesis that those with fear of LOC and those resigned to LOC would have greater psychopathology than those with neither fear nor resignation to LOC was partially supported. Global eating-disorder psychopathology was more severe amongst participants with fear of LOC than those resigned to LOC and without fear/resignation, and more severe amongst those resigned to LOC than those without fear/resignation. Binge-eating episode frequency was higher amongst those resigned to LOC than those with no fear/resignation, but fear of LOC did not differ significantly from other groups. Patients with binge-eating disorder who experienced fear of LOC had more distress and higher depression than those with no fear/resignation; however, those resigned to LOC did not differ significantly from the other groups. Significant associations were characterized by small and small-medium effect sizes, and a medium-large effect size of global eating disorder severity. Effect sizes indicate that while anticipatory cognitive-affective experiences account for some differences in clinical psychopathology, they do not explain psychopathology fully. Our findings add to previous research on the association of fear of LOC and eating-disorder psychopathology, suggesting that among patients with binge-eating disorder, fear of LOC is significantly associated with eating-disorder psychopathology and negative affect, and additionally, resignation to LOC is significantly associated with eating-disorder psychopathology.

Extending prior research that has only focused on fear of LOC (not resignation to LOC), we found that treatment-seeking patients with binge-eating disorder who experienced fear of LOC had greater distress, depression, and global eating-disorder psychopathology than those with no fear/resignation. This extension is important because fear of LOC has not been examined among treatment-seeking patients with binge-eating disorder. Overall, our findings suggest that fear of LOC is indicative of a more severe clinical presentation, although notably, patients with fear of LOC did not have greater frequency of binge-eating episodes, nor younger age of onset, than those with no fear/resignation. This is notable because the DSM-5 uses frequency of binge-eating episodes to categorize severity (American Psychiatric Association, 2013), and duration of illness has received attention as an indicator of severity and prognosis for recovery (e.g., Hornberger et al., 2021).

Our research extends past work by examining a novel, related construct: resignation to LOC. Prior work has documented that patients can feel helpless in the face of their eating disorder, as though their eating disorder forces them to act in ways they would not choose to act and has been associated with over-controlled eating and negative affect (Mullen et al., 2020), but has not been examined related to binge eating. Resignation to LOC is the feeling that patients are helpless to control the binge episode from occurring. In the current study, resignation to LOC was associated significantly with higher binge-eating episode frequency and global eating-disorder psychopathology compared to no fear/resignation. The higher binge-eating episode frequency amongst those with resignation to LOC compared to those with no fear/resignation suggests that resignation may indicate a more severe clinical picture than no fear/resignation. This is in contrast to fear of LOC, which did not differ significantly from other groups in binge-eating frequency. Future research should investigate potential mechanisms between resignation to LOC and binge-eating behaviors and frequency. Neither fear of LOC nor resignation to LOC, however, were associated age of onset, suggesting that anticipatory cognitive-affective experiences are associated with psychopathology and are not a progression of the disorder (for example, if there was a progression, then fear of LOC might become resignation to LOC over time as patients begin to believe they cannot escape binge eating; however, we did not find significant differences by age of onset). Longitudinal research tracking patients’ cognitive-affective experiences should clarify whether there is a trajectory amongst patients who experience resignation to LOC.

Although resignation to LOC presents a more severe clinical presentation than no fear/resignation, patients resigned to LOC were significantly lower than those with fear of LOC on global eating-disorder psychopathology. This suggests that although patients resigned to LOC may have more severe psychopathology than patients with no fear/resignation, they appear to have less severe psychopathology overall than those with fear of LOC. Future research should examine other clinical indices, including impairment and quality of life.

There were significant differences between the three binge-eating disorder study groups categorized based on LOC in demographic characteristics. Fewer men with binge-eating disorder endorsed fear of LOC than women; however, gender proportions did not differ significantly between those resigned to LOC and those with fear of LOC and those with no fear/resignation. This finding aligns with prior research suggesting that men experience some aspects of binge eating differently than women. For example, one study that examined how men describe overeating, specifically around control and antecedents, found that men perceived overeating but not LOC to be consistent with the male gender role, despite reporting behaviors similar to LOC such as eating more than planned and feeling overpowered by food (Carey et al., 2017). The same study also found that men described “stress” prior to overeating, but not “fear” (Carey et al., 2017). Our findings also suggested that individuals identifying as Black were more likely to report no fear/resignation than other categories, but otherwise there were no significant racial/ethnic differences. This is partially in contrast to the limited research regarding ethnic and racial differences and fear of LOC, which suggests that fear of LOC may be higher amongst individuals who identify as Hispanic/Latinx compared to those who identify as Black or White (Bennett & Dodge, 2007). Moreover, preliminary evidence that fear of LOC is associated with different clinical features by race, for example, more strongly associated with depressive symptoms among individuals who identify as White and Asian/Pacific Islander than those who identify as Black or Hispanic/Latinx (Hazzard et al., 2019), highlights the importance of conducting further research testing racial/ethnic identity as potential moderators of treatment outcomes before assuming that interventions need to be tailored. Future research should also examine whether men and individuals identifying as Black might have lower endorsement of fear of LOC and resignation to LOC because of the potential barrier of endorsing language perceived to be outside of their perceived identity-based roles. In addition, given the limited research on fear of LOC and the absent research on resignation to LOC, future research should use mixed methods to understand, compare, and characterize experiences of fear of LOC and resigned LOC.

Finally, we examined whether patients with fear of LOC, resignation to LOC, or with no fear/resignation differed on frequency of meals and snacks consumed, based on prior research showing an association of LOC with fewer meals but more snacks consumed (Matheson et al., 2012). In our study, patients with binge-eating disorder who experienced fear of LOC and those who experienced resigned LOC consumed more snacks, but there was no difference by study group in meals consumed. This runs counter to conceptual models of binge eating, which proposes that skipping meals – one form of dietary restriction – is part of the cycle of binge eating. Our findings that patients with fear of LOC and resignation to LOC consumed more snacks than those with no fear/resignation of LOC is consistent, however, with the association in prior work between snacking and binge-eating episodes (Matheson et al., 2012). It is possible that individuals who eat more snacks experience fear or resignation about snacking becoming LOC. Prospective research, perhaps using ecological momentary assessment methodology, is needed to clarify the time course of behaviors, affect, and cognitions related to LOC.

The current study had both strengths and limitations. Strengths include the use of a well-established, investigator-based, semi-structured interview assessing eating-disorder psychopathology that was administered by trained doctoral-level clinicians. The cross-sectional nature of the study, however, precludes any conclusions about causality or possible temporal differences regarding fear of LOC, resignation to LOC, and no fear/resignation of LOC. Additionally, we assessed resignation to LOC in the absence of fear of LOC, not as an independent experience. It is possible, however, that individuals may experience fear of LOC and resignation to LOC at different times, which should be explored in future research. Finally, although there was some diversity in participants, the majority were well-educated, White, women. Findings may not generalize to groups not well-represented in this study.

This research was limited to patients with binge-eating disorder, yet individuals with bulimia nervosa, subthreshold binge-eating, or anorexia with binge eating, may experience fear of LOC or resignation to LOC. A patient’s anticipatory experiences of LOC associated with eating disorder diagnosis warrants exploration in clinical research and in treatment. Clinicians working from a behavioral approach should consider discussing antecedent affect and cognitions and how they relate to binge-eating behaviors and subsequent consequences. In particular, including fear of LOC and resignation to LOC in a treatment formulation could help identify intervention opportunities. From a cognitive approach (e.g., Fairburn, 2008), patients experiencing resigned LOC may benefit from learning to challenge unhelpful beliefs about powerlessness and control over subsequent binge-eating episodes. As a further example, from a dialectical behavior therapy approach (e.g., Safer et al., 2009), clinicians may need to help patients tolerate distress related to fearing losing control over eating.

Conclusion

In summary, findings from the current study suggest the utility of assessing for fear of LOC and resignation to LOC among treatment-seeking patients with binge-eating disorder. Across clinical variables, participants with fear of LOC broadly demonstrated greater psychopathology than those with no fear/resignation of LOC, with the exception of binge-eating frequency. Likewise, participants resigned to LOC broadly demonstrated greater psychopathology than those with no fear/resignation of LOC, with the exceptions of negative affect and distress about binge eating. Overall, findings inform future research and assessment of eating-disorder psychopathology by introducing resignation to LOC as a distinct construct from fear of LOC and no fear/resignation of LOC.

Public Significance Statement.

Adults with binge-eating disorder have anticipatory cognitive-affective experiences about loss of control (LOC) over eating (i.e., fear of LOC, resigned to LOC, no fear nor resignation of LOC). Individuals who experience fear of LOC and those who are resigned to LOC had more severe psychopathology than those without fear/resignation. Binge-eating disorder has the highest prevalence of the eating disorders; thus, findings have high public significance in guiding clinicians’ treatment planning.

Acknowledgements and Conflicts of Interest

This research was supported, in part, by National Institutes of Health grants R01 DK49587, K23 DK115893 and UL1 TR001863. This paper does not reflect the views of the Public Health Service nor the NIH. Funders played no role in the content of this paper.

The authors declare no conflicts of interest. Dr. Grilo reports several broader interests which did not influence this research or article; these include honoraria for lectures and CME activities at universities and scientific conferences, and Royalties from Guilford Press and Taylor & Francis Publishers for academic books. Dr. Lydecker reports honoraria for lectures at universities, community organizations, and scientific conferences that did not influence this research or article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request, including an approved protocol.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request, including an approved protocol.

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