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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: Eat Disord. 2019 May 11;29(1):42–55. doi: 10.1080/10640266.2019.1613847

Examination of Momentary Maintenance Factors and Eating Disorder Behaviors and Cognitions Using Ecological Momentary Assessment

Tyler B Mason 1, Kathryn E Smith 2,3, Ross D Crosby 2,3, Scott G Engel 2,3, Stephen A Wonderlich 2,3
PMCID: PMC6842669  NIHMSID: NIHMS1528989  PMID: 31081472

Abstract

The integrative cognitive-affective therapy (ICAT) momentary maintenance model proposes a number of situational factors that precipitate eating disorder (ED) behaviors and cognitions. The current study examines momentary situational triggers in relation to a broad range of ED symptoms in a diagnostically heterogeneous sample of individuals with ED psychopathology. In the current study, 30 women with binge eating pathology completed a 14-day EMA protocol during which they responded to five random signals throughout the day. During signaled assessments, participants completed measures of self-criticism, interpersonal problems, self-regulation of binge eating, appearance concerns, and cognitive and behavioral ED symptoms. Multilevel models were used to examine prospective associations between hypothesized ICAT maintenance factors and ED symptoms. Within-subjects self-criticism prospectively predicted vomiting, restriction, preoccupation with thoughts of food, and urges to eat. Within-subjects interpersonal problems prospectively predicted vomiting, and within-subjects appearance concerns prospectively predicted preoccupation with thoughts of food. There were no significant predictors of binge eating. These results provide some support for hypothesized momentary situational triggers of ED symptoms in the momentary maintenance model of ICAT using naturalistic, momentary assessment. Specifically, it may be particularly useful for interventions such as ICAT to address momentary self-criticism when targeting a range of ED symptoms.

Keywords: feeding and eating disorders, ecological momentary assessment, self-assessment, models, theoretical

A substantial body of literature has demonstrated the importance of momentary interpersonal, cognitive, and emotional processes that may serve to maintain eating disorder (ED) psychopathology (e.g., Fitzsimmons-Craft et al., 2016; Haedt-Matt & Keel, 2011; Ivanova et al., 2015). Such mechanisms are imperative to identify and target in the context of psychological and behavioral interventions, which often focus on specific episodes of behaviors and proximal contexts rather than distal events or risk factors. Informed by ecological momentary assessment (EMA) research, the theory underlying integrative cognitive affective therapy (ICAT) for bulimia nervosa (BN) integrates self-regulation, emotion regulation, and interpersonal perspectives to articulate several momentary factors that may potentiate bulimic behaviors (Wonderlich et al., 2008, 2015). These momentary precipitating factors are explicitly targeted during ICAT.

In particular, the ICAT maintenance model hypothesizes several momentary situations that are thought to elicit emotional responding and precipitate ED symptoms; in turn, ED symptoms serve a self-regulatory function by providing relief from negative affect, thereby perpetuating this psychopathology via negative reinforcement processes (Wonderlich et al., 2015). The situations precipitating negative affect and eating disorder behavior expectancies include negative self-evaluation, maladaptive self-directed behaviors (e.g., self-criticism), interpersonal problems, and food-related situations (e.g., exposure to eating-related stimuli, efforts to eat in a highly controlled manner). While ICAT has demonstrated efficacy in reducing ED and associated symptoms in BN (Wonderlich et al., 2014), there have been few empirical examinations of the momentary situational triggers that are posited to maintain ED symptoms within this framework. Such investigations may serve to advance theoretical perspectives and refine interventions by identifying specific maintenance mechanisms that are most relevant for different types of ED symptoms.

ICAT Momentary Triggers

Thus far, empirical and theoretical work has implicated the role of interpersonal problems and negative social evaluation as precipitants of ED symptoms (Ansell, Grilo, & White, 2012; Ivanova et al., 2015; Rieger et al., 2010; Wilfley et al., 2000). That is, the interpersonal model of binge eating posits that interpersonal difficulties lead to negative affect, and in turn, negative affect precipitates ED symptoms (Wilfley et al., 2000). Consistent with this model, at the momentary level, extant evidence from EMA studies has indicated interpersonal problems were predictive of loss of control eating in adolescents (Ranzenhofer et al., 2015), and that negative affect mediated momentary relationships between interpersonal stressors and binge eating and purging among women with bulimia nervosa (Goldschmidt et al., 2014).

Increasing research in psychopathology has also focused on the importance of self-criticism, which has often been studied as a vulnerability factor for depression and is associated with a range of psychiatric conditions (e.g., Kannan & Levitt, 2013). The ICAT framework conceptualizes self-criticism as a negative self-directed behavior that elicits states of negative affect, which is consistent with research that has identified self-criticism as a relevant and distinct factor related to facets of ED psychopathology, including binge eating (Dunkley & Grilo, 2007; Dunkley et al., 2010; Fenning et al., 2008). Furthermore, research in clinical samples demonstrated that higher self-criticism was related to greater shame and more severe ED symptoms over the course of treatment (Kelly & Tasca, 2016), and that shame mediated relationships between self-criticism and ED psychopathology (Kelly & Carter, 2013). However, thus far no studies have examined this construct as a momentary precipitant of ED symptoms.

In addition to more general forms of negative self-evaluation in EDs (e.g., low self-esteem, self-discrepancy), self-evaluation is often linked to appearance-related concerns and body dissatisfaction (e.g., Fairburn, Cooper, & Shafran, 2003). For example, evidence from naturalistic studies in college samples suggests that there is variability in state body dissatisfaction (e.g., Fitzsimmons-Craft et al., 2015; Melnyk, Cash, & Janda, 2004), and that state and trait body dissatisfaction or discrepancy are related to negative affect measured in naturalistic settings (Heron & Smyth, 2013; Leahy, Crowther, & Ciesla, 2011). Notably, one recent study found that momentary stress related to appearance was associated with subsequent binge eating and purging behaviors in women with anorexia nervosa (Mason et al., 2017). However, there remains limited evidence regarding the temporal relationships between state body dissatisfaction and other cognitive and behavioral ED symptoms in daily life.

Lastly, the ICAT maintenance model posits that eating-related situations may elicit emotional dysregulation among individuals with bulimic symptoms, though it is also possible that the relationship between situational cues and ED behaviors become automatic or habitual in nature without necessarily involving heightened emotional responding (Wonderlich et al., 2015). Such eating-related situations may include simple exposure to food, and/or attempts to maintain control over eating (Wonderlich et al., 2015). Prior research has demonstrated some support for the relationship between these types of situations and dysregulated eating. For instance, EMA studies have demonstrated that compared to individuals with lower BMI, individuals with relatively higher BMI were more susceptible to overeating in the presence of palatable food (Thomas, Doshi, Crosby, & Lowe, 2012), and higher momentary self-control depletion (i.e., high dietary restraint in conjunction with negative affect) was predictive of binge eating at moments when individuals with obesity endorsed higher negative affect eating expectancies – i.e., the belief that eating would relieve negative affect (Pearson et al., 2018).

The Present Study

Taken together, evidence to date has supported the importance of several components of the hypothesized ICAT maintenance model, though much of this research has relied on cross-sectional designs, and several constructs within this model have received little or no attention as momentary variables that potentiate ED cognitions and behaviors. Thus, the present study sought to examine the momentary situational triggers of ED symptoms that are hypothesized to potentiate ED symptoms in the ICAT model. While the ICAT maintenance model also posits mediators (i.e., negative affect, eating expectancies) of the relationships between these triggers and ED symptoms, as a first step, our aim was to examine main effects of theoretically based situations on eating behavior within this framework. Specifically, we examined these triggers (i.e., interpersonal problems, self-criticism, body dissatisfaction (as a proxy for self-evaluation), and attempts to control eating) as predictors of cognitive and behavioral ED symptoms (i.e., binge eating, vomiting, restriction, preoccupation with food, and urges to eat) among a sample of individuals who engage in regular binge eating. Doing so builds upon previous research by (1) examining each type of momentary situational trigger within ICAT in relationship to a broad range of ED symptoms, thereby providing a more comprehensive test of the ICAT theoretical model, and (2) examining these processes in a diagnostically heterogeneous sample of individuals with ED psychopathology, thereby enhancing the generalizability of the ICAT model of BN to binge eating more generally.

Method

Participants and Procedure

Thirty women with binge eating pathology (93% White) completed 14 consecutive days of EMA recordings. Binge eating pathology was defined as reporting at least one objective binge eating episode in the past month via clinical interview on the Eating Disorder Examination (Fairburn, Cooper, & O’Connor, 2008) and was used as an inclusion criterion for the study. Women were excluded for the following reasons: 1) inability to read or speak English; 2) current psychosis determined by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders - IV (SCID-I; First, Spitzer, Gibbon, & Williams, 2002); 3) current mania determined by the SCID-I; 4) acutely suicidal as determined by the Suicide Behavior Questionnaire-Revised (Osman et al., 2001); 5) current medical instability as determined by vital signs and blood pressure; 6) past year severe substance use disorder determined by the SCID-IV; 7) severe cognitive impairment or intellectual disability determined by phone screen; 8) currently pregnant or breastfeeding; 9) current or past four week inpatient or partial hospitalization in the past 4 weeks; and 10) changes to eating disorder treatment in the past four weeks. The mean age of the sample was 34.13 years (SD=13.92; Range=19-62), and the mean body mass index was 34.13 (SD=9.47; Range=18.43-57.83). Most of the sample met criteria for an eating disorder using the Eating Disorder Diagnostic Scale DSM-5 version (Stice, Telch, & Rizvi, 2000); see Table 1 for a breakdown of eating disorder diagnoses.

Table 1.

Eating Disorder Diagnoses of the Sample

Diagnosis N %
Anorexia nervosa 1 3.3
Bulimia nervosa 14 46.7
Binge eating disorder 6 20.0
Low frequency binge eating disorder 1 3.3
Night eating syndrome 1 3.3
No diagnosis 6 20.0
Missing 1 3.3
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The study was reviewed and approved by an institutional review board. Participants were recruited through clinical and community sites; potential participants were screened via phone or in-person at a clinic visit to evaluate initial study criteria. Those who met initial criteria and were interested completed an in-person study visit during which they completed the informed consent process as well as clinical interviews to assess eligibility criteria. Clinical interviews were given by trained master’s level assessors. Those who met all inclusion and exclusion criteria completed self-report questionnaires and received training on the EMA protocol, which included completing an EMA survey in-person and receiving definitions of ED behaviors.

The Real Time Assessment In the Natural Environment (RETAINE; retaine.org) system was used to administer EMA surveys via text message and web. Each day participants received five semi-random text messages delivered to their mobile phones administered within five pre-determined windows starting in the morning through the evening. These windows varied around five anchor points: 9AM, 12PM, 3PM, 6PM, and 9PM. They were provided a link in which to complete the EMA survey. Participants had an hour to complete the survey before they could no longer access the survey, which prevented backlogging of EMA reports. During the recordings, participants were asked about ED behaviors, mood, and other momentary contextual factors. A research assistant called participants halfway through the EMA protocol to remind participants about compliance and answer questions/concerns. Participants received $110 for completion of in-person clinical interviews and assessments, and $2 per signal that they completed during the EMA protocol.

Measures

Momentary interpersonal problems.

Five items from the Social Adjustment Scale - Self-Report (SAS-SR; Weissman & Bothwell, 1976) were used to assess interpersonal problems. Consistent with previous EMA research (Ranzenhofer et al., 2014), participants indicated the extent since the last signal to which they argued with someone, felt rejected, felt lonely, wished their relationships were better, and wished they had more friends on a scale from 1 (not at all) to 5 (extremely).

Momentary self-criticism.

Items were adapted for EMA from self-report surveys of self-criticism (Gilbert, Clark, Hempel, Miles, & Irons, 2004). Participants denoted the extent to which they were “disappointed with yourself”, “putting yourself down”, “having self-critical thoughts”, “disliking yourself”, and “dwelling on your failings” at the current moment using a scale from 1 (not at all) to 5 (extremely).

Momentary appearance concerns.

Four items from the State Self-Esteem Scale (SSES; Heatherton & Polivy, 1991) appearance subscale was used to measure momentary appearance concerns. Participants were instructed to indicate the extent to which they felt satisfied with the way their body looks, dissatisfied with their weight, pleased with their appearance right now, and unattractive at each signal on a scale ranging from 1 (not at all) to 5 (extremely). This measure has been used in previous EMA research (Leahey, Crowther, & Ciesla, 2011).

Momentary eating-related situations.

For this study, self-regulation of binge eating was assessed as an eating-related situation during which individuals endorsed attempting to prevent binge eating. Participants were asked to indicate on a scale from 1 (not at all) to 5 (extremely), “Right now, to what extent are you forcing yourself to NOT binge eat?” This item was modified for the current study from an EMA item assessing general momentary self-regulation (Buchholz, 2015).

ED behaviors and cognitions.

Binge eating and vomiting were assessed by having participants indicate at each recording whether they engaged in either behavior since their last recording. Restriction was assessed by having participants indicate whether they “ate less to control their weight.” ED cognitions were assessed with items from the Appetite Scale (Kikuchi, Yoshiuchi, Inada, Ando, & Yamamoto, 2015). At each signal, participants were instructed to describe their current urge to eat and preoccupation with thoughts of food on a visual analog scale anchored with 1 (none) and 100 (intense).

Statistical Analyses

Descriptive statistics and multilevel reliability estimates (ω; Geldhof, Preacher, & Zyphur, 2014) were computed. Univariate general estimating equations (GEEs) were used to examine predictors of ED behaviors and cognitions. The autoregressive (AR1) serial autocorrelation correction was used to account for dependencies within the nested data (Schwartz & Stone, 1998). Time-lagged variables (i.e., t-1) were calculated within-day for momentary predictors to assess relationships with dependent variables (i.e., ED behaviors and cognitions) at the subsequent signal. First and last measurements of the day were not lagged to prior day or next day assessments. Predictor variables were partitioned into between-subjects (individual differences) that were grand-mean centered and within-subjects (momentary) effects that were person-mean centered, with individuals as the Level 2 and EMA observations as the Level 1 unit of analysis. For dichotomous dependent variables, GEEs employed binary logistic functions, whereas linear functions were used for continuous dependent variables. Each predictor was tested in relation to each dependent variable in separate models. Age and body mass were screened for inclusion in models; they were significantly associated with ED cognitions but not ED behaviors and were thus included as covariates in ED cognition models.

Results

There were 1,558 total EMA recordings. The mean number of signals completed was 51.93 (SD=13.49; Range=16-70). The overall compliance rate was 78.3%. The number of EMA recordings completed was unrelated to demographic variables. Over the course of the EMA period, there were 213 binge eating episodes, 63 vomiting episodes, and 195 restriction episodes. Within-subjects internal consistency reliabilities (ωs) based upon multilevel reliability estimates were .97 for self-criticism, .83 for interpersonal problems, and .80 for appearance concerns, and between-subjects ωs were .99 for self-criticism, .90 for interpersonal problems, and .94 for appearance concerns.

Table 2 displays the within- and between-subjects effects of momentary factors in relation to ED behaviors and cognitions. Within-subjects self-criticism prospectively predicted vomiting, restriction, preoccupation with thoughts of food, and urges to eat. That is, at moments when participants reported greater self-criticism, they were more likely to report vomiting, restriction, preoccupation with thoughts of food, and urges to eat at the next signal. Within-subjects interpersonal problems prospectively predicted vomiting, suggesting that at moments participants reported greater interpersonal problems, they were more likely to engage in vomiting at the next signal. Within-subjects appearance concerns prospectively predicted preoccupation with thoughts of food only. Thus, at moments participants reported greater appearance concerns, they reported higher preoccupation with thoughts of food at the next signal.

Table 2A.

General Estimating Equations of ICAT Momentary Maintenance Factors Predicting Eating Disorder Behaviors

Binge Eating Vomiting Restriction
B p B p B p
Within-subjects interpersonal problems −0.02 .87 0.30 .04 0.15 .16
Between-subjects interpersonal problems 0.01 .95 0.260 .49 0.57 .03
Within-subjects self-criticism 0.05 .56 0.32 .03 .26 .01
Between-subjects self-criticism −0.07 .70 −0.03 .92 .30 .17
Within-subjects appearance concerns 0.20 .24 0.17 .53 0.31 .21
Between-subjects appearance concerns 0.28 .41 0.22 .60 0.72 .06
Within-subjects eating-related situations 0.03 .71 −0.07 .59 0.08 .34
Between-subjects eating-related situations −0.08 .75 0.11 .82 0.68 .02
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Note. Models were run separately for all predictors, and each predictor model included both the between- and within-subjects effect. ICAT-integrative cognitive affective therapy.

Between-subjects interpersonal problems were associated with more restriction, suggesting that participants who reported relatively greater interpersonal problems compared to the overall sample engaged in more restriction throughout the EMA protocol. Between-subjects self-regulation of binge eating was also associated with increased restriction, preoccupation with thoughts of food, and urges to eat, such that participants who report relatively greater self-regulation of binge eating compared to other participants engaged in more restriction, had more preoccupation with thoughts of food, and more urges to eat. There were no significant between- or within-subjects predictors of binge eating.

Discussion

This study evaluated hypothesized momentary situational triggers of ED symptoms in the momentary maintenance model of ICAT using EMA. Within-subjects self-criticism emerged as a significant predictor of ED behaviors (i.e., vomiting and restriction) and cognitions (i.e., preoccupation with thoughts of eating and urges to eat), and thus, was the most potent momentary predictor of ED symptoms of all of the variables we evaluated. This extends cross-sectional research that has found positive associations between self-criticism and ED psychopathology (Dunkley & Grilo, 2007; Dunkley et al., 2010; Fenning et al., 2008) to a prospective and momentary research design. Further, it suggests that momentary, within-subjects self-criticism is more salient than between-subjects levels of self-criticism, which highlights the importance of identifying and targeting intra-individual processes that potentiate ED symptoms. Consistent with ICAT, momentary self-criticism may precipitate increasing negative affect (Zuroff, Sadikaj, Kelly, & Leybman, 2016), which in turn leads to ED behaviors and cognitions (Smyth et al., 2007); thus, this possibility represents an important question for future EMA research.

Notably, momentary interpersonal problems and appearance concerns predicted a smaller range of outcomes compared to self-criticism. Within-subjects interpersonal problems prospectively predicted vomiting, which is in line with EMA research in women with bulimia nervosa (Goldschmidt et al., 2014). In addition, within-subjects appearance concerns prospectively predicted preoccupation with thoughts of food. It may be that interpersonal problems and appearance concerns are more proximally associated with other ED behaviors that we investigated. Future research should further elucidate the temporal processes linking momentary interpersonal problems and vomiting, and momentary appearance concerns and preoccupation with thoughts of food. For example, momentary appearance concerns may lead to attentional biases toward weight, shape, and food cues, which in turn lead to more preoccupation with thoughts of food (Rosser, Moss, & Rumsey, 2010).

Contrary to expectations, within-subjects efforts to regulate binge eating did not predict any ED symptoms. Such eating-related situations may be most strongly related to ED symptoms within minutes, and thus the schedule of signals in the present study may have failed to capture such relationships. For example, someone’s ability to self-regulate their binge eating may affect their likelihood of engaging in binge eating or restriction in a particular moment as opposed to two hours later. However, between-subjects self-regulation of binge eating was associated with increased restriction, preoccupation with thoughts of food, and urges to eat. These factors may be related because they serve as trait-like indicators of food-related cognitions and attempts to control them.

Perhaps the most surprising null findings in the current study were that there were no significant within- or between-subjects predictors of binge eating. There are some possible reasons for these results. First, some evidence suggests that over time binge eating may become habitual (Pearson, Wonderlich, & Smith, 2015); thus, reducing the strength of putative predictors of the behavior. Second, binge eating is difficult to define and measure given the subjectivity of binge eating criteria. Dimensional scales of overeating and loss of control, as opposed to dichotomous measures (did or did not occur) may be useful for improving measurement of binge eating in EMA. Distinguishing between loss of control and overeating may be important in future studies as some research suggests that loss of control specifically is related to distress and impairment (Goldschmidt, 2017). Third, the association between the momentary situational factor that we examined and binge eating may be dependent upon intrapersonal or contextual factors (e.g., affect, availability of food, location). The affective and cognitive experience around ED behaviors is a highly dynamic process, and future studies could benefit from a higher sampling frequency (Kockler, Santangelo, & Ebner-Priemer, 2018).

There were several limitations of this study worth noting. The unidimensional approach to assessing binge eating may not have adequately captured binge eating compared to approaches that use multiple items. We did not use event-contingent reporting of eating episodes, which has been commonly used in previous studies of binge eating (e.g., Engel et al., 2013; Smyth et al., 2007). Event-contingent reporting of eating episodes could have increased accuracy in timing and reporting of ED behaviors and cognitions. Further, there is always the possibility that the occurrence of some ED behaviors were not reported. In addition, while EMA is the best methodology available for assessing momentary relations in the natural environment, EMA measurements may have been too far apart to capture more proximal relations. Also, while trans-diagnostic approaches to intervention and prevention research have advantages, we did not have adequate sample size of individual diagnoses to determine if risk factors differed by diagnosis. In addition, our sample was mostly Caucasian and all women, which limits generalizability to other racial groups and men.

Conclusions

Taken together, the present study extends the existing literature on momentary triggers of ED symptoms and offers directions for future work. Specifically, momentary, within-subjects predictors emerged as stronger predictors of ED behaviors compared to between-subjects predictors. A particularly unique and meaningful contribution was the finding that momentary self-criticism emerged as a salient predictor of a range of ED outcomes, which is consistent with the ICAT maintenance model and adds to previous literature examining this construct in EDs.

Importantly, targeting self-criticism and associated feelings of shame may be especially relevant in the context of ICAT and other interventions. For instance, components of interventions (e.g., ICAT, compassion-focused therapy) that specifically target self-criticism and shame via cultivation of self-compassion and more positive self-directed style may be particularly effective in this respect (Kelly & Carter, 2017; Wonderlich et al., 2015). However, additional work is needed to test momentary mediational processes by which self-criticism, as well as interpersonal problems and appearance concerns, lead to ED symptoms, as well as assess other relationships examined in the present study in closer temporal proximity. Further, future work should study multivariate models that examine the most potent predictors of ED symptoms and should assess assessing interactive effects of momentary variables to provide more nuanced information about the specific contexts surrounding ED symptoms in daily life.

In addition, one of the strongest translational opportunities with EMA findings going forward is the development of novel ecological momentary interventions (EMIs; Heron & Smyth, 2014). EMIs are interventions that occur in individuals’ daily life that provide intervention material in real-life when it is most crucial. The current findings suggest that EMIs could be developed to target self-criticism in daily life in order to prevent ED behaviors and cognitions from occurring. By intervening upon self-critical thoughts when they occur by providing coping and supportive strategies (e.g., self-compassion), ED behaviors and cognitions may be prevented.

Table 2B.

General Estimating Equations of ICAT Momentary Maintenance Factors Predicting Eating Disorder Cognitions.

Preoccupation Urges
B P B p
Within-subjects interpersonal problems 1.58 .12 0.71 .42
Between-subjects interpersonal problems 4.16 .54 2.62 .65
Within-subjects self-criticism 3.73 <.001 3.25 <.001
Between-subjects self-criticism 5.22 .27 3.76 .49
Within-subjects appearance concerns 3.94 .01 2.54 .15
Between-subjects appearance concerns 8.05 .15 5.15 .35
Within-subjects eating-related situations 1.16 .17 2.06 .03
Between-subjects eating-related situations 19.19 <.001 18.06 <.001
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Note. Models were run separately for all predictors, and each predictor model included both the between- and within-subjects effect. ICAT = integrative cognitive affective therapy. Age and body mass index were controlled for in analyses

Clinical Implications.

  • Within-subjects self-criticism prospectively predicted vomiting, restriction, thoughts of food, and urges at the momentary, within-day level.

  • Also, within-subjects interpersonal problems prospectively predicted vomiting, and within-subjects appearance concerns prospectively predicted thoughts of food at the momentary, within-day level.

  • Helping patients recognize and cope with momentary feelings of self-criticism, interpersonal problems, and appearance concerns may be effective at preventing the occurrence of eating disorder behaviors and cognitions.

Acknowledgements:

This work was funded partially by the National Institute of Mental Health (T32MH082761).

Footnotes

Conflict of Interest Statement: The authors have no conflicts of interest to disclose.

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