Abstract
Objective:
Non-purging compensatory behaviors (NPCB; e.g., driven exercise, fasting, other extreme behaviors) are a subcategory of compensatory behaviors typically characterized as infrequent and less severe. Limited prior research has studied NPCB despite their increasing prevalence among adults with binge-spectrum eating disorders (B-ED). More research is needed to understand the types of NPCB present among B-ED and the association between NPCB, clinical severity, and treatment outcomes.
Method:
Secondary analyses were conducted among 155 adults with B-ED in cognitive-behavioral (CBT)-based clinical trials. At baseline and post-treatment, clinical interviews of eating pathology assessed binge eating frequency, purging compensatory behavior frequency, and global eating pathology. The following NPCB were also assessed: driven exercise, 24-hour fasting, 8+ waking hours of compensatory fasting, chewing and spitting, and other extreme weight control behaviors.
Results:
Participants engaging in NPCB reported higher global eating pathology than those not engaging in NPCB. Frequency of chewing and spitting and 24-hr fasting significantly decreased over treatment. Engagement in NPCB at baseline did not predict CBT outcomes.
Discussion:
The current study highlights the prevalence and clinical severity of NPCB in B-ED, but offers promising results regarding the potential for CBT to improve these behaviors. More research is needed on other extreme weight control behaviors reported qualitatively in our sample and on the maintenance of improvements in non-purging behaviors after CBT.
Keywords: binge eating, binge eating disorder, bulimia nervosa, compensatory behaviors
Introduction
Compensating for eating through behaviors intended to influence shape and weight is a transdiagnostic symptom of eating disorders (“Feeding and Eating Disorders,” 2013). Although a diagnostic feature of Bulimia Nervosa (BN), compensatory behaviors occur in other binge-spectrum eating disorders (e.g., Binge-Eating Disorder (BED), Other Specified Feeding or Eating Disorders (OSFED)) although less frequently (Basdevant et al., 1995; Johnson et al., 2021). Compensatory behaviors have serious cardiovascular and digestive health impacts (Academy for Eating Disorders’ Medical Care Standards Committee, 2016) and are positively associated with eating disorder severity (Colleen Stiles-Shields et al., 2012). Considering their adverse effects, it is important to have a complete understanding of types of compensatory behaviors and their unique association with clinical severity and treatment outcomes for binge-spectrum eating disorders (B-ED).
The DSM-5-TR categorizes compensatory behaviors as purging (i.e., self-induced vomiting, laxative and diuretic misuse) and non-purging compensatory behaviors (NPCB; e.g., fasting, driven exercise). NPCB are portrayed in the DSM-5-TR as rare (“Feeding and Eating Disorders,” 2013), and previous research found no relationship between NPCB and eating disorder severity (Abebe et al., 2012; Mond et al., 2006). However, this conceptualization may be inaccurate. First, driven exercise and fasting are frequently reported by individuals with B-ED (Elran-Barak et al., 2015; Monell et al., 2018) and associated with more severe eating pathology (Cuccolo et al., 2022; Monell et al., 2018). Second, the DSM-5-TR and previous literature does not include other clinically significant compensatory behaviors that are increasingly prevalent. For example, chewing and spitting food to control weight is endorsed by around 25% of individuals with eating disorders and associated with more frequent binge eating and purging behaviors and more severe global eating pathology (Makhzoumi et al., 2015; Song et al., 2015). Lastly, patients with eating disorders often clinically report other potentially harmful behaviors to avoid weight gain (e.g., diet pills, excessive time spent in saunas or wearing waist trainers), yet these other extreme weight control behaviors have not been well-defined or studied. In sum, the perception of NPCB as infrequent and less severe than purging compensatory behaviors has been contraindicated by recent research and neglects other empirically or clinically observed NPCB (e.g., chewing and spitting, other extreme weight control behaviors).
Additionally, more research is needed about the impact of NPCB on treatment outcomes for B-ED. Prior meta-analyses suggest that cognitive behavioral therapy (CBT), the gold-standard treatment for B-ED, reduced overall compensatory behavior engagement by 78% (Anderson & Maloney, 2001). However, these studies did not compare treatment outcomes for purging compensatory behaviors versus NPCB . Understanding if CBT is effective for reducing NPCB and whether engaging in NPCB impacts treatment outcomes from CBT will address a major gap in the literature and provide critical information for clinicians.
The current study first aimed to characterize the type and frequency of NPCB in a transdiagnostic B-ED sample, including qualitative reports of other extreme weight control behaviors. Second, the study aimed to test the hypothesis that greater binge eating frequency, purging compensatory behavior frequency, and global eating pathology would be associated with engagement and frequency of total and individual categories of NPCB (i.e., driven exercise, fasting, chewing and spitting, other extreme weight control behaviors). Third, the study tested the hypothesis that NPCB frequency will significantly decrease across CBT. Fourth, the study tested the hypothesis that baseline NPCB engagement would not significantly affect CBT outcomes.
Methods
Participants and Procedures
The study was a secondary data analysis from four recently completed outpatient clinical trials of CBT for B-ED (Juarascio et al., 2021; Juarascio et al., 2023; Juarascio et al., 2022; Manasse et al., 2020). Inclusion criteria for all studies required participants to have a B-ED diagnosis (i.e., 12+ objective or subjective binge eating episodes in the past 3 months), but varied in terms of other eating disorder symptoms. For example, 36.1% of the sample were enrolled in a clinical trial requiring 12+ compensatory behaviors for inclusion, and 19.4% of the sample were enrolled in a trial requiring 5+ hours of fasting for inclusion. The clinical trials varied in length (63 participants received 16 sessions, and 92 participants received 12 sessions), session duration (148 participants received 60-minute sessions, and 7 participants received 45-minute sessions), and additive therapeutic components (i.e., glucose monitoring, just-in-time adaptive interventions, acceptance and commitment therapy skills, inhibitory control training).
Participants (N = 155) were on average 39.12 years old (SD = 12.57). The majority identified as women (84.5%), while others identified as men (12.9%), non-binary (0.6%), or other (0.6%). The participants’ racial backgrounds included White (73.5%), Black or African American (9.7%), Asian (4.5%), American Indian/Native American (0.6%), more than one race (5.8%), unknown or prefer not to say (1.3%), and other (3.2%), with 1.3% having missing data for this item. Baseline diagnoses included BN (58.1%), BED (24.5%), or OSFED (17.4%).
Measures
The Eating Disorder Examination interview (EDE 17.0) (Fairburn et al., 1993) was used to assess eating pathology over the past three months. Binge eating frequency was defined as the total number of objectively and subjectively large binge-eating episodes. Compensatory behaviors were categorized into purging (i.e., self-induced vomiting, laxative misuse, or diuretic misuse episodes) and non-purging compensatory behaviors (i.e., driven exercise, 24-hour fasting, compensatory fasting of 8 or more waking hours after binge-eating episodes, chewing and spitting, and other extreme weight control behaviors). Other extreme weight control behaviors met the following criteria per EDE guidelines: (1) be intended to control weight and/or shape, (2) have the potential for negative health or psychosocial consequences, and (3) be potentially effective in changing shape and weight (Fairburn et al., 1993). EDE global score was calculated to reflect cognitive eating disorder symptoms (i.e., dietary restraint, concerns about eating, weight, or shape) (Cronbach’s alpha = 0.87). The EDE has demonstrated good reliability and validity in prior research (Cooper et al., 1989). Trained assessors, with at least a bachelor’s degree and over 40 hours of supervised training, administered the EDE.
Statistical Plan
Data analysis was performed using SPSS 29.0. Apriori power analyses determined that between 77 – 92 participants were required for linear regressions testing between 3 – 5 predictors (depending on study aim) to detect a medium-sized effect with 80% statistical power; the study was adequately powered given the sample size of 155 participants. Assumptions of linear regressions (e.g., linearity, homoscedasticity, lack of multicollinearity) were met for each study aim. For Aim 1, descriptive statistics were calculated to characterize NPCB. For Aim 2, separate linear regressions assessed the relationship between NPCB engagement or frequency and baseline binge eating frequency, purging compensatory behavior frequency, and EDE global scores. All three clinical severity markers were entered as predictors for each model to assess for independent relationships when controlling for other variables. Given the large number of statistical tests, the Benjamini–Hochberg (B-H) correction was used (Benjamini & Hochberg, 1995); only p-values less than the B-H critical values were interpreted as significant. Data imputation was conducted to address missingness from treatment non-completers (n = 23). For Aim 3, linear regressions examined changes in NPCB frequency during treatment, controlling for study length, session duration, and baseline purging compensatory behavior frequency. For Aim 4, linear regressions tested if baseline NPCB engagement predicted treatment outcomes, when controlling for baseline severity, baseline purging compensatory behavior frequency, study length, and session duration.
Results
Aim 1: Characterization of non-purging compensatory behaviors
Table 1 displays descriptive statistics and qualitative descriptions of other extreme weight control behaviors. At baseline, 99 participants (63.87%) reported NPCB in the past three months, and 89 participants (57.42%) reported past-month NPCB. At post-treatment, 26 participants (19.70%) reported past-month NPCB. Five participants who did not report NPCB at baseline initiated these behaviors during treatment and reported past-month NPCB engagement at post-treatment. Specifically, new onset of NPCB was reported by two participants for chewing and spitting and three participants for driven exercise in the past month at post-treatment.
Table 1.
Descriptives and change over treatment for non-purging behavior engagement in the past month.
| Past Month Behaviors | Baseline | Post-Treatment | t | p | sr2 |
|---|---|---|---|---|---|
| Any Non-Purging Behaviors |
n = 89 (57.42%) M =8.59 SD =12.67 Min = 0, Max = 68 |
n = 26 (19.70%) M = 2.03 SD =6.59 Min = 0, Max = 42 |
0.49 | 0.62 | < 0.01 |
| Chewing and Spitting |
n = 19 (12.26%) M = 0.71 SD: 2.89 Min = 0, Max = 28 |
n = 9 (6.82%) M = 0.17 SD = 0.75 Min = 0, Max = 5 |
2.43 | 0.02 | 0.04 |
| Driven Exercise |
n = 57 (36.77%) M = 3.99 SD = 7.04 Min = 0, Max = 28 |
n = 19 (14.39%) M =1.44 SD = 4.98 Min = 0, Max = 27 |
0.85 | 0.40 | < 0.01 |
| 24-hr Fasting |
n = 22 (14.19%) M = 0.39 SD =1.14 Min = 0, Max = 8 |
n = 1 (0.76%) M = 0.02 SD = 0.17 Min = 0, Max = 2 |
2.41 | 0.03 | 0.07 |
| Compensatory Fasting |
n = 52 (33.55%) M = 1.98 SD = 0.29 Min = 0, Max = 21 |
n = 4 (3.03%) M = 0.25 SD =1.95 Min = 0, Max = 20 |
1.54 | 0.12 | 0.02 |
| Other Extreme Weight Control Behaviors | n = 17 (10.97%) M = 2.47 SD = 8.42 Min = 0, Max = 54 - Diet pills (e.g., Hydroxycut, Natrol, Tonalin, Ritalin, Phentermine, non-prescription fat-burner pills) for appetite suppressant effect (n = 9) - Enemas for laxative effect (n = 2) - Wearing a waist trainer while exercising or for long duration (e.g., 8-10 hours) for appetite suppressant effect (n = 2) - ½ cup of apple cider vinegar for laxative effect (n = 2) - Cigarette smoking for appetite suppression (n = 1) - Wrapping self in plastic or wearing a sauna suit in the sauna (n = 1) - Eating Metamucil mixed with small amount of water as appetite suppressant (n = 1) |
n = 1 (0.76%) M = 0.28 SD = 3.26 Min = 0, Max = 25 - Waist shaper and sweat gel while sleeping (n = 1) - Diet pills (e.g., Hydroxycut) for appetite suppressant effect (n = 1) |
0.48 | 0.64 | < 0.01 |
Aim 2: Relationship between non-purging compensatory behaviors and clinical severity
Except for chewing and spitting, individuals who endorsed all other types of NPCB reported significantly higher EDE global scores compared to individuals who did not endorse NPCB at baseline (Table 2). Individuals who endorsed any NPCB, driven exercise, and 24-hr fasting at baseline reported significantly lower binge eating frequency than individuals not engaging in NPCB at baseline. No differences were observed between groups in terms of purging compensatory behavior frequency.
Table 2.
Relationship between baseline clinical severity and engagement or frequency in non-purging compensatory behaviors.
| No Engagement in Past 3 Mo M (SD) |
Engaged in Past 3 Mo M (SD) |
NPCB Engagement | NPCB Frequency | ||||||
|---|---|---|---|---|---|---|---|---|---|
| B | t-value | B-H critical value | B | t-value | B-H critical value | ||||
| Total NPCB | BE Freq. | 90.73 (58.91) n = 56 |
75.93 (55.63) n = 99 |
0.00 | −2.85 | 0.011* | 0.00 | −0.04 | 0.050 |
| Purging Freq. | 25.59 (68.08) n = 56 |
27.86 (55.82) n = 99 |
0.00 | 0.33 | 0.044 | −0.04 | −0.57 | 0.039 | |
| EDE Global | 2.46 (0.98) n = 56 |
3.28 (0.93) n = 99 |
0.21 | 5.76 | 0.001* | 14.46 | 3.02 | 0.010* | |
| Chewing and Spitting | BE Freq. | 79.91 (56.92) n = 132 |
89.13 (58.74) n = 23 |
0.00 | −0.43 | 0.042 | 0.03 | 1.29 | 0.029 |
| Purging Freq. | 23.80 (57.56) n = 132 |
45.61 (73.00) n = 23 |
0.00 | 1.34 | 0.028 | 0.00 | −0.09 | 0.046 | |
| EDE Global | 2.89 (1.02) n = 132 |
3.53 (0.85) n = 23 |
0.08 | 2.04 | 0.021 | −0.43 | −0.29 | 0.049 | |
| Driven Exercise | BE Freq. | 90.11 (61.97) n = 91 |
68.72 (46.99) n = 64 |
0.00 | −3.89 | 0.004* | −0.09 | −1.89 | 0.024 |
| Purging Freq. | 21.82 (59.24) n = 91 |
34.45 (61.55) n = 64 |
0.00 | 2.34 | 0.017 | 0.04 | 0.96 | 0.032 | |
| EDE Global | 2.77 (1.06) n = 91 |
3.29 (0.88) n = 64 |
0.13 | 3.29 | 0.008* | 5.20 | 1.85 | 0.025 | |
| 24-hr Fasting | BE Freq. | 85.24 (57.47) n = 119 |
68.19 (54.55) n = 36 |
0.00 | −2.55 | 0.015* | −0.02 | −2.08 | 0.019 |
| Purging Freq. | 26.03 (63.34) n = 119 |
30.36 (49.73) n = 36 |
0.00 | 0.76 | 0.035 | 0.01 | 0.61 | 0.038 | |
| EDE Global | 2.84 (0.99) n = 119 |
3.46 (0.98) n = 36 |
0.12 | 3.66 | 0.007* | 1.48 | 2.83 | 0.013* | |
| Comp. Fasting | BE Freq. | 81.06 (58.69) n = 86 |
85.53 (58.20) n = 58 |
0.00 | −0.67 | 0.036 | 0.05 | 1.95 | 0.031 |
| Purging Freq. | 23.98 (63.33) n = 86 |
29.52 (57.94) n = 58 |
0.00 | −0.32 | 0.044 | −0.03 | −1.25 | 0.022 | |
| EDE Global | 2.58 (0.97) n = 86 |
3.44 (0.87) n = 58 |
0.21 | 5.48 | 0.003* | 3.51 | 2.33 | 0.018 | |
| Other Extreme Weight Control Behaviors | BE Freq. | 80.88 (54.74) n = 138 |
83.06 (77.73) n = 16 |
0.00 | −0.83 | 0.033 | 0.00 | 0.11 | 0.026 |
| Purging Freq. | 25.63 (58.25) n = 138 |
40.56 (78.29) n = 16 |
0.00 | 0.45 | 0.040 | −0.06 | −1.59 | 0.047 | |
| EDE Global | 2.87 (0.98) n = 138 |
3.85 (0.97) n = 16 |
0.09 | 3.73 | 0.006* | 6.70 | 2.82 | 0.014* | |
B-H critical values that are greater than p-values, and are considered significant after using the Benjamini–Hochberg correction method.
Among individuals reporting NPCB at baseline (n = 99), frequency of total NPCB, 24-hr fasting, and other extreme behaviors was associated with higher EDE global scores at baseline (Table 2). Frequency of any NPCB categories were not associated with binge eating or purging compensatory behavior frequency.
Aim 3: Non-purging compensatory behavior change over treatment
After controlling for study length, session duration, and baseline purging compensatory behavior frequency, linear regressions determined a significant decrease in chewing and spitting frequency and 24-hr fasting frequency from baseline to post-treatment. There was no significant change in overall NPCB, driven exercise, compensatory fasting, and other extreme behavior frequency over treatment.
Aim 4: Non-purging compensatory behavior engagement as a predictor of treatment outcomes
When controlling for baseline severity, baseline purging compensatory behavior frequency, study length, and session duration, NPCB engagement did not significantly predict binge eating frequency (t(1) = −0.15, p = 0.88, sr2 < 0.01), purging compensatory behavior frequency (t(1) = 0.74, p = 0.46, sr2 < 0.01), or EDE global score (t(1) = −0.39, p = 0.70, sr2 < 0.01).
Discussion
The current study assessed the relationship between NPCB, clinical severity, and treatment outcomes in individuals with B-ED receiving outpatient CBT. Nearly two-thirds of participants reported NPCB at baseline, with driven exercise and compensatory fasting being the most common behaviors. Although differences in study inclusion criteria could have potentially impacted prevalence and frequency of NPCB, the prevalence of NPCB endorsed by a given study was proportional to the percentage of participants from the study in the sample. For example, 48.4% of participants endorsing driven exercise were from the study requiring 12+ compensatory behaviors for inclusion (36.1% of the sample), and 29.3% of participants endorsing compensatory fasting were from the study requiring 5+ hours of fasting for inclusion (19.35% of the sample). While only seventeen participants reported other extreme weight control behaviors at baseline, the qualitative descriptions of these behaviors varied considerably and included the use of diet pills, enemas, waist trainers, and over-consumption of apple cider vinegar. Considering the potential negative medical consequences, future research should quantitatively measure the other extreme weight control behaviors identified in this study.
The current study found that NPCB engagement and frequency was positively related to global eating pathology for all behaviors except chewing and spitting. These results differ from previous research indicating no relationship between NPCB engagement and clinical severity (Abebe et al., 2012; Mond et al., 2006), but are consistent with research demonstrating that individual categories of NPCB are related to higher symptom severity (Aouad et al., 2018; Cuccolo et al., 2022; Mitchell et al., 1991; Song et al., 2015). The more detailed assessment of NPCB used in the current study likely contributed to our results by increasing the quality of our data and elucidating patterns between NPCB and clinical severity. Contrary to hypotheses, engagement in total NPCB, driven exercise, and 24-hr fasting was related to lower binge eating frequency. These results could suggest that cognitive rather than behavioral eating disorder symptoms are more severe among individuals engaging in NPCB, however more research is needed to study this association further. Future research should aim to replicate our results using similar assessment methods. Despite the associations with severity at baseline, the current study found that NPCB engagement did not impact treatment outcomes.
Chewing and spitting and 24-hr fasting significantly improved over treatment after controlling for differences between studies and baseline purging compensatory behavior frequency, suggesting that CBT for B-ED is effective for reducing these NPCB. These NPCB reductions are likely due to CBT’s strong emphasis on regular eating and reducing strict dietary rules. Although not statistically significant, over half of participants initially engaging in NPCB at baseline stopped these behaviors by post-treatment. Despite these promising results, a subset of individuals reported NPCB at post-treatment, with the most common behaviors being chewing and spitting and driven exercise. Additionally, five participants initiated chewing and spitting or driven exercise over treatment. These findings emphasize the importance of ongoing clinical assessment of NPCB engagement, particularly chewing and spitting and driven exercise, throughout treatment.
Strengths of the current study include the comprehensive assessment of specific NPCB through clinical interviews and the use of both cross-sectional and longitudinal methods to examine the relationship between NPCB, clinical severity, and treatment outcomes. However, several limitations should be acknowledged. First, the current study relied on secondary data from four clinical trials for B-ED, which differed in specific aspects of treatment (e.g., length, session duration) and inclusion criteria. We chose to combine samples and covary for study in analyses to increase statistical power, but future research should explore these relationships in a single treatment sample. Second, the current study did not assess session-by-session changes in compensatory behavior engagement and clinical outcomes, which could provide valuable insight into when targeted intervention is needed to improve outcomes for NPCB. Third, our study did not evaluate the maintenance of improvements in NPCB frequency in the months following treatment. Future research should address these limitations to enhance our understanding of NPCB in B-ED.
Clinical Implications.
Non-purging compensatory behaviors exist across binge-spectrum eating disorders.
Participants with non-purging compensatory behavior engagement reported more severe eating pathology than those without.
Cognitive-behavioral treatment for binge eating improves most non-purging compensatory behaviors.
Clinicians should monitor for changes or new onset of non-purging compensatory behaviors.
Acknowledgements
The current study used data from the following NIMH-funded clinical trials: R43-MH-121205, R34-MH-116021, R01-MH-122392, R34-MH-118353.
Footnotes
Conflict of Interest
The authors declare that there are no conflicts of interest.
Ethical Statement
The current study was approved by the Drexel University Institutional Review Board.
Data Availability Statement
Data from the current study will be available upon reasonable request.
References
- Abebe DS, Lien L, Torgersen L, & von Soest T (2012). Binge eating, purging and non-purging compensatory behaviours decrease from adolescence to adulthood: A population-based, longitudinal study. BMC Public Health, 12(1), 1–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Academy for Eating Disorders’ Medical Care Standards Committee. (2016). Eating disorders: A guide to medical care. https://higherlogicdownload.s3.amazonaws.com/AEDWEB/27a3b69a-8aae-45b2-a04c-2a078d02145d/UploadedImages/AED_Medical_Care_Guidelines_English_04_03_18_a.pdf
- Anderson DA, & Maloney KC (2001). The efficacy of cognitive-behavioral therapy on the core symptoms of bulimia nervosa. Clinical Psychological Review, 21(7), 971–988. 10.1016/s0272-7358(00)00076-3 [DOI] [PubMed] [Google Scholar]
- Aouad P, Hay P, Soh N, & Touyz S (2018). Prevalence of chew and spit and its relation to other features of disordered eating in a community sample. International journal of eating disorders, 51(8), 968–972. 10.1002/eat.22873 [DOI] [PubMed] [Google Scholar]
- Basdevant A, Pouillon M, Lahlou N, Le Barzic M, Brillant M, & Guy-Grand B (1995). Prevalence of binge eating disorder in different populations of French women. International journal of eating disorders, 18(4), 309–315. 10.1002/1098-108X(199512)18:4 [DOI] [PubMed] [Google Scholar]
- Benjamini Y, & Hochberg Y (1995). Controlling the False Discovery Rate: A Practical and Powerful Approach to Multiple Testing. Journal of the Royal Statistical Society. Series B (Methodological), 57(1), 289–300. http://www.jstor.org/stable/2346101 [Google Scholar]
- Colleen Stiles-Shields E, Labuschagne Z, Goldschmidt AB, Doyle AC, & Le Grange D (2012). The use of multiple methods of compensatory behaviors as an indicator of eating disorder severity in treatment-seeking youth. International journal of eating disorders, 45(5), 704–710. 10.1002/eat.22004 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Cooper Z, Cooper PJ, & Fairburn CG (1989). The validity of the eating disorder examination and its subscales. The British Journal of Psychiatry, 154(6), 807–812. [DOI] [PubMed] [Google Scholar]
- Cuccolo K, Kramer R, Petros T, & Thoennes M (2022). Intermittent fasting implementation and association with eating disorder symptomatology. Eating Disorders, 30(5), 471–491. 10.1080/10640266.2021.1922145 [DOI] [PubMed] [Google Scholar]
- Elran-Barak R, Sztainer M, Goldschmidt AB, Crow SJ, Peterson CB, Hill LL, Crosby RD, Powers P, Mitchell JE, & Le Grange D (2015). Dietary Restriction Behaviors and Binge Eating in Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder: Trans-diagnostic Examination of the Restraint Model. Eating Behaviors, 18, 192–196. 10.1016/j.eatbeh.2015.05.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Fairburn CG, Cooper Z, & O’Connor M (1993). The eating disorder examination. International Journal of Eating Disorders, 6, 1–8. [Google Scholar]
- Feeding and Eating Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders. APA. 10.1176/appi.books.9780890425787.x10_Feeding_and_Eating_Disorders [DOI] [Google Scholar]
- Johnson SN, Forbush KT, Swanson TJ, & Christensen KA (2021). An empirical evaluation of the diagnostic threshold between full-threshold and sub-threshold bulimia nervosa. Eating Behaviors, 42, 101540. 10.1016/j.eatbeh.2021.101540 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Juarascio AS, Felonis CR, Manasse SM, Srivastava P, Boyajian L, Forman EM, & Zhang F (2021). The project COMPASS protocol: Optimizing mindfulness and acceptance-based behavioral treatment for binge-eating spectrum disorders. International journal of eating disorders, 54(3), 451–458. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Juarascio AS, Presseller EK, Srivastava P, Manasse SM, & Forman EM (2023). A Randomized Controlled Trial of CBT+: A Clinician-Controlled, Just-In-Time, Adjunctive Intervention for Bulimia-Spectrum Disorders. Behavior Modification, 47(3), 551–572. 10.1177/01454455221109434 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Juarascio AS, Srivastava P, Presseller EK, Lin M, Patarinski AG, Manasse SM, & Forman EM (2022). Using continuous glucose monitoring to detect and intervene on dietary restriction in individuals with binge eating: The SenseSupport withdrawal design study. JMIR Formative Research, 6(12), e38479. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Makhzoumi SH, Guarda AS, Schreyer CC, Reinblatt SP, Redgrave GW, & Coughlin JW (2015). Chewing and spitting: a marker of psychopathology and behavioral severity in inpatients with an eating disorder. Eating Behaviors, 17, 59–61. 10.1016/j.eatbeh.2014.12.012 [DOI] [PubMed] [Google Scholar]
- Manasse SM, Lampe EW, Gillikin L, Payne-Reichert A, Zhang F, Juarascio AS, & Forman EM (2020). The project REBOOT protocol: Evaluating a personalized inhibitory control training as an adjunct to cognitive behavioral therapy for bulimia nervosa and binge-eating disorder. International journal of eating disorders, 53(6), 1007–1013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Mitchell JE, Pyle RL, & Eckert E (1991). Sauna abuse as a clinical feature of bulimia nervosa. Psychosomatics, 32(4), 417–419. 10.1016/S0033-3182(91)72044-6 [DOI] [PubMed] [Google Scholar]
- Mond JM, Hay PJ, Rodgers B, & Owen C (2006). Eating Disorder Examination Questionnaire (EDE-Q): norms for young adult women. Behavioral Research and Therapy, 44(1), 53–62. 10.1016/j.brat.2004.12.003 [DOI] [PubMed] [Google Scholar]
- Monell E, Levallius J, Forsen Mantilla E, & Birgegard A (2018). Running on empty - a nationwide large-scale examination of compulsive exercise in eating disorders. Journal of Eating Disorders, 6, 11. 10.1186/s40337-018-0197-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- Song YJ, Lee JH, & Jung YC (2015). Chewing and spitting out food as a compensatory behavior in patients with eating disorders. Comprehensive Psychiatry, 62, 147–151. 10.1016/j.comppsych.2015.07.010 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data from the current study will be available upon reasonable request.