Eating Behaviors 15 (2014) 192–196

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Eating Behaviors

Course and moderators of emotional eating in anorectic and bulimicpatients: A follow-up study

Giulia Fioravanti a, Giovanni Castellini b, Carolina Lo Sauro a, Sirio Ianni b, Luca Montanelli b, Francesco Rotella b,Carlo Faravelli a, Valdo Ricca b,⁎a Department of Health Sciences, Section of Psychology and Psychiatry, University of Florence, Viale Pieraccini 6, 50139 Florence, Italyb Psychiatric Unit, Careggi Teaching Hospital, Largo Brambilla 3, 50134 Florence, Italy

⁎ Corresponding author. Tel.: +39 0557947487; fax: +E-mail address: valdo.ricca@unifi.it (V. Ricca).

1471-0153/$ – see front matter © 2014 Elsevier Ltd. All rihttp://dx.doi.org/10.1016/j.eatbeh.2014.01.006

a b s t r a c t

a r t i c l e i n f o

Article history:Received 9 September 2013Received in revised form 10 December 2013Accepted 22 January 2014Available online 1 February 2014

Keywords:Eating DisordersEmotional eatingFollow-up studyCocaine abuseAmphetamine abuse

Emotion dysregulation has been found to be associatedwith specific eating attitudes and behavior in Eating Dis-order (ED) patients. The present study evaluated whether emotional eating profile of ED patients changes overtime and the possible effects of a psychotherapeutic intervention on the emotional eating dimension. One hun-dred and two ED patients (28 with Anorexia Nervosa restricting type [AN-R], 35 with Anorexia Nervosa binge/purging subtype [AN-B/P] and 39with BulimiaNervosa [BN])were evaluated at baseline, at the end of a CognitiveBehavioral Therapy, at 3 and 6 year follow-up. The Structured Clinical Interview for DSM IV Axis I Disorders, theEmotional Eating Scale (EES) and several self-reported questionnaires for eating specific and general psychopa-thology were applied. A control group of 86 healthy subjects was also studied, in order to compare psychopath-ological variables at baseline. A significant EES total score reduction was observed among AN-B/P and BNpatients, whereas no significant change was found in the AN-R group. Mixed Models analyses showed that asignificant effect on EES total score variationwas found for cocaine or amphetamine abuse (b= .25; p b .01). Pa-tients who assumed these substances reported no significant EES reduction across time, unlike other patients.The present results suggest that ED patients with a history of cocaine or amphetamine abuse represent a sub-population of patients with lasting dysfunctional mood modulatory mechanisms.

© 2014 Elsevier Ltd. All rights reserved.

1. Introduction

Emotion dysregulation has recently been considered a trans-diagnostic factor related to multiple types of psychopathology (Ehring&Watkins, 2008), and different associations between emotion dysregu-lation and symptoms of depression, anxiety, and substance abuse havebeen observed (Aldao, Nolen-Hoeksema, & Schweizer, 2010). As far asEating Disorder (ED) are concerned, patients often show relevant diffi-culties in emotion regulation, due to the lack of the skills required tocope with negative affective states (Svaldi, Griepenstroh, Tuschen-Caffier, & Ehring, 2012), and different authors consider ED symptoms(e.g. binge eating and purging behaviors) as pathological responses toregulate intense or relatively undifferentiated emotional states, to re-strict the affective experience or to deviate attention from negativeemotions (Torres et al., 2010; Treasure, Claudino, & Zucker, 2010;Zaitsoff & Grilo, 2010; Espeset, Gulliksen, Nordbø, Skårderud, & Holte,2012).

Emotional eating (EE) has been defined as the tendency to eat in re-sponse to emotional states (Arnow, Kenardy, & Agras, 1995), and it wasidentified as a possible factor triggering binge eating in Bulimia Nervosa(BN) (Engelberg, Steiger, Gauvin, & Wonderlich, 2007), and in Binge

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Eating Disorder (BED) (Masheb & Grilo, 2006; Zeeck, Stelzer, Linster,Joos, & Hartmann, 2010). This construct is not merely focused on eatingbehavior and overeating, but it specifically addresses the feelings thatlead people to experience an urge to eat and the desire of consumingfood in response to different emotions (Arnow et al., 1995). Recentstudies suggested that EE is not only associated with the presence ofbinge eating, but is also a common dimension in all EDs (Courbasson,Rizea, &Weiskopf, 2008; Torres et al., 2010; Ricca et al., 2012). In partic-ular, it has been observed that EE is significantly associatedwith specificeating attitudes and behavior, according to the different ED diagnoses:restraint for patients with Anorexia Nervosa restricting type (AN-R),subjective binge eating for patients with Anorexia Nervosa binge/purging type (AN-B/P), and objective binge eating for patients withBN (Ricca et al., 2012). Overall, these findings seem to support thosemodels which conceptualize EDs as syndromes that are characterizedby the impairment in the cognitive capacity to process and regulateemotions as the primary regulatory disturbance (Kenardy, Arnow, &Agras, 1996; Stein et al., 2007).

However, despite the relevant role of emotional eating in EDs, to ourknowledge there are no previously published studies that have evaluat-ed the course of emotional eating in a clinical setting. Therefore, it is un-known whether emotional eating profile of ED patients changes overtime andwhich are the possible effects of a psychotherapeutic interven-tion on this psychopathological dimension.

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The aims of the present study were as follows:

- to evaluate the course of emotional eating over time in patients withAN and BN

- to assess the possible predictors of emotional eating change.

2. Methods

The study was performed at the Eating Disorder Outpatient Clinic ofthe Psychiatric Unit of the Careggi University Hospital of Florence, Italy.A written informed consent was obtained from each patient and theprotocol was approved by the Ethics Committee of the Institution. Allpatients who attended the Outpatient Clinic between June 2003 andDecember 2005 were included in the study. The exclusion criteriawere illiteracy, comorbidity with schizophrenia or bipolar disorder,andmental retardation. Patients were treated with an individual Cogni-tive Behavioral Therapy (which is the standard intervention for outpa-tients at our clinic) which applies validated behavioral and cognitivestrategies widely used in the treatment of these patients. AN patientswere provided an individual CBT consisting of about 40 hour-longmanual-based sessions conducted over a minimum of 40 weeks. Inthe present study, we used CBT as described elsewhere (Pike, Loeb, &Vitousek, 1996; Garner, Vitousek, & Pike, 1997). BN patients were treat-ed with an individual CBT, according to themanual of Fairburn, Marcus,andWilson (1993). At the endof treatment (T1), 3 years after the endoftreatment (T2) and 6 years after the end of treatment (T3), the patientswere contacted by telephone and invited to the clinic for a follow-upvisit. Drop out occurred for 6 AN patients (9.5%), and for 5 BN patients(12.8%). Four AN patients (6.3%), and 3 BN patients (7.6%) were lost tofollow-up. Only patients assessed at all the three follow-upwere includ-ed into the final analyses. Therefore, the final sample was composed of102 women aged ≥18 years with EDs: 28 with a diagnosis of AN-R,35 with AN-B/P and 39 with BN. A control group of healthy subjectswas considered to compare psychopathological variables at baseline.The control group was enrolled according to the following procedure:each control was extracted from the alphabetical computerized list ofclients of a general practitioner and was selected as the first one fulfill-ing the inclusion criteria andwilling to participate. In the case of refusal,the next one on the list, fitting the matching criteria, was asked to par-ticipate. The control inclusion criteria were as follows: age between18and 60 years and BMI ranging between 18 and 24.9 kg/m2. The exclu-sion criteria were the same with that of the patient groups, plus the ab-sence of any actual and lifetime eating disorder or other psychiatricdisorder diagnosis, according to DSM-IV criteria, evaluated by meansof a face-to-face interview (Structured Clinical Interview for DSM-IV).Eight subjects were excluded from the initial list of controls because ofthe following reasons: refuse to give their informed consent (4), illiter-acy (3), andmental retardation (1). The final healthy control groupwascomposed by 86 subjects, aged mean 28.86 ± 7.70 years, with a meanBMI of 22.02 ± 2.99 kg/m2.

The sociodemographic data were evaluated by a psychiatrist and theanthropometric measurements were made using standard calibrated in-struments. In order to perform the ED and comorbid Axis I diagnoses pa-tients were interviewed by either one of two expert clinicians (V.R., G.C.),by means of the Structured Clinical Interview for DSM IV Axis I Disorders(SCID-I) (First, Spitzer, Gibbon, &Williams, 1995). The number of weeklyobjective binge eating and subjective binge eating episodes was evaluat-ed by means of a face-to-face clinical interview, according to specificquestions extracted from the Eating Disorder Examination Interview(EDE 12.0D) (Fairburn & Cooper, 1993) and fromDSM-IV (Text Revision)(American Psychiatric Association, 2000). Moreover participants com-pleted the following self-reported questionnaires, in order to collectdata on eating and general psychopathology: the Emotional Eating Scale(EES) (Arnow et al., 1995), the Eating Disorder Examination Question-naire (EDE-Q) (Fairburn & Beglin, 1994), the Beck Depression Inventory(BDI) (Beck & Steer, 1987), the State–Trait Anxiety Inventory (STAI

form Y-1) (Spielberger, Gorsuch, & Lushene, 1970), the Barratt Impulsiv-ity Scale (BIS-11) (Patton, Stanford, & Barratt, 1995) and the SymptomChecklist (SCL-90-R) (Derogatis, Lipman, & Covi, 1973). Emotional EatingScale is a 25-item self-report questionnaire that indicates the extent towhich specific feelings lead a subject to feel an urge to eat. Each item con-sists of an emotion term (e.g., jittery, angry, and helpless), and the 5-pointscale used was anchored on a continuum from “no desire to eat” to “anoverwhelming urge to eat”. The 25 items form 3 subscales, reflecting eat-ing in response to anger (Anger/Frustration), anxiety (Anxiety), and de-pressed mood (Depression). These 3 subscales refer to the emotionalantecedents of binge eating, and on each scale, higher scores reflect agreater tendency to eat in response to emotional state. TheEES is internal-ly consistent, it demonstrates temporal stability and it has good construct,criterion, and discriminant validity (Arnow et al., 1995). In the currentsample internal consistency was good (Cronbach's alpha: 0.92). Theself-reported EDE-Q consists of 38 items, assessing the core psychopath-ological features of eating disorders, and contains 4 subscales: dietary re-straint, eating concern, weight concern, and shape concern. The dietaryrestraint subscale is an admixture of cognitions and behaviors pertainingtodietary restriction. The three other subscales evaluate thedysfunctionalattitudes regarding eating and overvalued thoughts regardingweight andshape. The global score represents the mean of the four subscale scores(Fairburn & Beglin, 1994). The EDE-Q has good concurrent validity(Mond, Hay, Rodgers, Owen, & Beumont, 2004a, 2004b), a high degreeof temporal stability (Mond et al., 2004a, 2004b) and reliability (Berg,Peterson, Frazier, & Crow, 2012). In the current sample internal consisten-cy was good (Cronbach's alpha: 0.80). The Beck Depression Inventory(Beck & Steer, 1987) is a 21-item self-reporting scale that assesses the se-verity of affective, cognitive, motivational, vegetative, and psychomotorcomponents of depression. Each item is a list of four statements arrangedby the increasing severity of a particular symptom of depression; thehigher the score, the higher is the depression. The BDI showed excellentpsychometric properties (Beck, Steer, & Carbin, 1988). In the current sam-ple Cronbach's alpha was 0.91. The STAI (Spielberger et al., 1970) is a 40-item measure that indicates the intensity of feelings of anxiety. It distin-guishes between state anxiety (i.e., a temporary condition experiencedin specific situations) and trait anxiety (i.e., a general tendency toperceivesituations as threatening). It showed good psychometric properties(Spielberger et al., 1970) and in the present sample internal consistencywas good (Cronbach's alpha was 0.91). The BIS-11 (Patton et al., 1995)is a questionnaire designed to assess the personality/behavioral constructof impulsiveness. It is the most widely cited and psychometrically soundinstrument for the assessment of impulsiveness. Cronbach's alpha in thecurrent study was 0.83.

Finally, SCL-90-R (Derogatis et al., 1973) is a good psychometric in-strument devoted to the identification of the psychopathologic distress.In the current sample Cronbach's alpha was 0.95.

Chi-square test and one-way analysis of variance (ANOVA) test forindependent samples with Tukey's post hoc test were performed tocompare socio-demographic and clinical variables between groups.ANOVA Mixed Models with random intercept were performed to eval-uate emotional eating levels over time and the effect of the baseline var-iables on emotional eating change. EES total score was entered asdependent variable and age, BMI, age of onset, psychiatric comorbidi-ties, ED diagnosis, and psychopathological variables at the baselinewere entered as covariates, considering them as potential moderatorsof emotional eating change across time.

The Statistical Package for the Social Sciences (SPSS; SPSS Inc.,Chicago, IL) for Windows 18.0 was used for data analysis.

3. Results

3.1. Study variables at baseline

Descriptive statistics of the study variables at the baseline for thethree groups and controls are reported in Table 1. Patients and controls

Table 1Comparisons of the study variables at the baseline among the three ED groups and controls.

AN-R (N = 28)M ± SD

AN-B/P (N = 35)M ± SD

BN (N = 39)M ± SD

Controls (N = 86)M ± SD

F p

Age (years) 25.93 ± 8.94 25.77 ± 8.80 30.72 ± 9.25 28.86 ± 7.60 3 .03Education (years) 14.22 ± 3.37 12.46 ± 3.26 14.54 ± 3.38 10.18 ± 5.31a,c 9.02 b0.001Age of onset (years) 16.42 ± 3.23 16.26 ± 2.53 19.65 ± 8.29 – 2.36 0.10BMI 15.94 ± 2.68 16.74 ± 1.90 23.59 ± 6.30a,b 22.02 ± 2.99 a,b 36.90 b0.001SCL-90 GSI 0.96 ± 0.60 1.49 ± 0.85 1.08 ± 0.86 0.58 ± 0.45 1.96 0.15BDI 15.93 ± 10.43 21.14 ± 10.13 24.57 ± 13.97 3.79 ± 4.11a,b,c 43.98 b0.001BIS 53.79 ± 12.39 56.13 ± 7.86 62.1 ± 17.01 55.98 ± 17.35 1.44 0.23STAI-S 49.07 ± 23.34 50.82 ± 31.33 58.43 ± 12.88 25.69 ± 22.43a,b,c 16.26 b .001STAI-T 47.71 ± 18.97 48.82 ± 25.67 56.05 ± 11.90 24.07 ± 20.25 a,b,c 20.17 b .001OBE 0.13 ± 0.45 6.81 ± 8.35a 10.11 ± 10.07a 0.23 ± 0.96b,c 30.78 b0.001SBE 4.80 ± 7.04 7.28 ± 7.98 6.46 ± 7.73 0.20 ± 0.77a,b,c 18.76 b0.001Purging behavior 1.42 ± 4.48 2.47 ± 3.51 4.14 ± 6.53 0a,b,c 11.47 b0.001EDE-Q total score 2.66 ± 1.41 3.43 ± 1.24 3.30 ± 1.32 0.84 ± 0.83a,b,c 66.36 b0.001EDE-Q R 2.20 ± 1.79 3.32 ± 1.72 2.94 ± 1.79 0.85 ± 1.05a,b,c 30.22 b0.001EDE-Q EC 2.46 ± 1.52 3.03 ± 1.41 3.13 ± 1.20 0.39 ± 0.58a,b,c 83.83 b0.001EDE-QWC 2.58 ± 1.45 3.21 ± 1.29 3.27 ± 1.40 0.98 ± 0.96a,b,c 45.36 b0.001EDE-Q SC 3.46 ± 1.70 3.88 ± 1.37 3.87 ± 1.66 1.15 ± 1.08a,b,c 53.38 b0.001EES total score 1.26 ± 0.82 1.53 ± 1.03 1.97 ± 1.00a 0.76 ± 0.70b,c 18.25 b0.001EES Ang/Frust 1.17 ± 0.83 1.37 ± 0.98 1.93 ± 1.02a,b 0.66 ± 0.72b,c 19.05 b0.001EES Anx 1.37 ± 0.97 1.48 ± 0.99 1.83 ± 0.92 0.75 ± 0.68a,b,c 15.58 . b 0.001EES Dep 1.50 ± 0.91 1.69 ± 0.86 2.30 ± 1.08a,b 1.07 ± 0.96b,c 13.43 b0.001

OBE: Objective Binge Eating (month frequency); SBE: Subjective Binge Eating (month frequency); BIS: Barratt Impulsiveness Scale; STAI-S: State Anxiety Inventory; STAI-T: Trait AnxietyInventory; EDE-Q R: Eating Disorder Examination Questionnaire Restraint; EDE-Q EC: Eating Disorder Examination Questionnaire Eating Concern; EDE-QWC: Eating Disorder Examina-tion QuestionnaireWeight Concern; EDE-Q SC: Eating Disorder Examination Questionnaire Shape Concern; EES Ang/Frust: Emotional Eating Scale Anger/Frustration; EES Anx: EmotionalEating Scale Anxiety; EES Dep: Emotional Eating Scale Depression.

a vs AN-R.b vs AN-B/P.c vs BN.

194 G. Fioravanti et al. / Eating Behaviors 15 (2014) 192–196

differed in terms of all the psychopathological variables taken into ac-count. In particular, control subjects showed lower scores on emotionaleating as compared to all the ED groups. These differences were not sta-tistically significant when comparisons were made between controlsand AN-R group. As expected, BN patients showed higher BMI, as com-pared with AN patients. No significant differences were detected be-tween patient groups, in terms of main psychiatric comorbidities(Unipolar Depression: 25.6% BN patients, 17.9% AN-R and 22.9% AN-B/P; χ2 = 0.56, p = 0.75; Obsessive–Compulsive Disorder: 10.3% BNpatients, 17.9% AN-R and 8.6% AN-B/P; χ2 = 0.54, p = 0.76; PanicDisorder: 12.8% BN patients, 10.7% AN-R and 14.3% AN-B/P; χ2 = 0.17,p = 0.91). Eighteen patients (17.6% of the total sample: 9.8% BN pa-tients, 3.9%AN-R and3.9%AN-B/P; χ2= 2.86, p= 0.24) fulfilled criteriaof a lifetime diagnosis of cocaine or amphetamine abuse. A significantdifference for EES total score was found between AN-R and BN patients,with the latter showing higher levels. Furthermore, BN patients showedhigher EES anger/frustration and depression subscale scores than AN-Rand AN-B/P patients, while no significant differencewas found betweenAN subgroups.

3.2. Emotional eating variation over time

As far as EES variation across time, a significant EES total score reduc-tion was observed among AN-B/P and BN patients, whereas no signifi-cant change was found for AN-R group (Fig. 1a). Considering EESsubscales, a significant decrease was found for anger/frustration sub-scale (b = − .23; p b .05), for anxiety subscale (b = − .24; p b .01)and for depression subscale (b = − .29; p b .01) among BN patients. Asignificant decrease for anxiety subscale (b=− .23; p b .05) and for de-pression subscale (b = − .27; p b .01) was also found among AN-B/Pgroup. No significant variation was found for EES subscales amongAN-R patients.

3.3. Predictors of emotional eating change over time

As far as moderators of EE variation are concerned, a significant ef-fect on EES total score variation was found for cocaine or amphetamine

abuse (b= .25; p b .01), but not with other psychiatric comorbidities orwith other variables listed in Table 1 which resulted to be not signifi-cantly associatedwith EES change across time. In particular, a significantEES reductionwas observed for those patients who never assumed sub-stances. Fig. 1b showed the effect of the diagnosis of cocaine or amphet-amine abuse on the EES total score change. Patients who have not takensubstances at the baseline showed a significant decrease of emotionaleating levels over time.

3.4. Association between outcomes and emotional eating

As far as the diagnostic outcomes are concerned, the overall recoveryrate was 50.0% for AN-R, 57.1% for AN-B/P, and 56.4% for BN, while thecrossover (diagnostic change) rate was 14.3% for AN-R, 31.4% for AN-B/P, and 15.4% for BN. Emotional eating levels at baseline did not showany significant association with diagnostic outcomes. No significant in-teractionwas found between EES change over timewith recovery (timeby recovery interaction— AN-R: b= 0.03, p= 0.80; AN-B/P: b = 0.06,p= 0.62; BN: b= 0.17, p= 0.26) or diagnostic change (time by cross-over interaction — AN-R: b = 0.07, p = 0.79; AN-B/P: b = 0.18, p =0.19; BN: b = 0.12, p = 0.52).

4. Discussion

To the best of our knowledge, this is the first study which evaluatedthe long term outcome of emotional eating in AN and BN patients. Thelack of previous studies on this topic did not allow to formulate specifica priori hypotheses, and the results of the present study should be con-sidered as explorative.

According to the main findings of the present study:

- emotional eating levelswere found to be reduced across time in bothBN and AN–B/P patients, whereas no significant change was foundfor AN-R group;

- patients reporting a lifetime diagnosis of cocaine or amphetamineabuse did not show a significant improvement in emotional eatinglevels across time.

Fig. 1. Emotional eating change over time. a. Differences between Eating Disorder groups (BN: Bulimia Nervosa; AN-B/P: Anorexia Nervosa binge/purging; AN-R: Anorexia Nervosarestricting subtype) on variation of emotional eating (EES: Emotional Eating Scale) over different time points (0: baseline; 1: end of treatment; 2: 3 year follow-up; 3: 6 year follow-up). b. Effect of the diagnosis of cocaine or amphetamine abuse on emotional eating change. Statistics for panels a and b: ANOVA Mixed Models with random intercept were performedto evaluate emotional eating levels over time and the effect of the baseline variables (diagnosis in panel a, substance abuse in panel b) on emotional eating change.

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All ED patient groups showed high levels of emotional eating. How-ever, after CBT, only those patients with binge/purging behaviors (BNand AN-B/P), and not AN-R patients, showed significant improvements.Wemight argue that emotional eatingwas a specific target of CBT inter-vention only for those patients who reported binge eating (Fairburn,Cooper, & Shafran, 2003). Therefore, it is possible that thepoor improve-ment of emotional eating in AN-R patients was explained by the differ-ences in CBT treatment. However, it should be considered that the EESdefined emotional eating as a “desire to eat in response to a range ofnegative emotions”, rather than “eating in response to a range of nega-tive emotions” (Arnow et al., 1995). In fact, emotional eating is presentin anorectic patients, aswell, and it is associated to restraint (Ricca et al.,2012). According to Heatherton and Baumeister (1991), extreme foodrestriction, as well as binge eating, helps individuals to escape fromaversive self-awareness, which includes negative self-perceptions andemotional distress. Thus, traditional CBT intervention, targeting emo-tional dysregulation only in those patients with loss of control over eat-ing, will probably “forget” a relevant psychological dimension which ispresent in most ED patients. This observation can explain the poor im-provement of emotional eating in AN patients. In fact, while the loss ofcontrol over eating is approached by several traditional CBT strategies(e.g., problem solving), emotional eating as the desire to eat and notpurely the act of eating is not specifically treated.

Furthermore, we found that patients who did not use cocaine or am-phetamines showed a significant reduction of emotional eating levels at

all three time points (post-treatment, 3-year follow-up and 6-year fol-low up), while patients who have taken these substances did notshow significant changes in emotional eating over time. Substanceabuse has been associated with several medical and psychological com-plicationswhich could be responsible of emotional eatingmaintenance,including tolerance within a few months of treatment (Mathys, 2005;Harrold & Halford, 2006; Fernstrom & Choi, 2008; Devlin, Goldfein,Carino, & Wolk, 2000) and an impairment of one's sense of hungerand satiety (Spitzer et al., 1993; Yanovski & Sebring, 1994; Masheb &Grilo, 2006; Sysko, Devlin, Walsh, Zimmerli, & Kissileff, 2007). Theresulting reduction of the appetite suppressant activity and the alteredsense of hunger and satiety play a significant role in the eating behaviorsof these subjects. In fact, theywould ingest foodmore frequently as a re-sult of coping to an emotional or a cognitive state, rather than of physi-ological needs. Moreover, the use of these substances could lead in thelong term to a lower one's self-confidence in the ability to control eatingand properly regulate emotional states, given their sympathomimeticeffect on hypothalamic and limbic regions of the brain (Bray, 1993).Therefore, it is possible that patients with previous cocaine or amphet-amine abuse represent a sub-population of patients with “resistant”dysfunctional mood modulatory mechanisms. Indeed, previous studies(Garner &Gerborg, 2004;Macht, 2005; Courbasson et al., 2008) have in-dicated that eating disorders and substance use disorders both cover theuse ofmaladaptive behaviors to copewith negativemood states and areboth characterized by emotional dysregulation (Spence & Courbasson,

196 G. Fioravanti et al. / Eating Behaviors 15 (2014) 192–196

2012). As Courbasson et al. (2008) stated, emotional eating and sub-stance use may be related to the tendency to be over-absorbed by in-stead of acting on stressful situations.

The present results should be considered in the light of some limita-tions: different self-reported measures were applied, thus possibly de-termining potential subjective bias. Furthermore, errors or memorybiases could have affected the retrospectively collected data such asthe use of substances, and information regarding the possible psycho-pathological and clinical changes within each time points are lacking.Temperament and personality disorders were not assessed. This couldbe relevant, considering their important mediating role for differentclinical variables considered in this study. Our findings refer to patientsseeking treatment and cannot be generalized to the whole populationwith these syndromes. The limited sample size could have reducedthe power of the study. Data about other substance commonly used(e.g. marijuana) were not available.

In conclusion, emotional eating is a relevant dimension in all ED cat-egories and differently changes across time. Approaches specifically fo-cused on the impaired cognitive capacity to process and regulateemotions would improve the way these patients cope with negativeself-awareness. The assessment of a history of substance abuse in EDpa-tients is crucial, because this particular anamnestic information allowsto identify a sub-population of patients with a different course of illnessand a different response to cognitive behavioral strategies, in terms ofemotion regulation.

Role of the funding sourcesNo financial support has been provided for this study.

ContributorsValdo Ricca, Giovanni Castellini and Carlo Faravelli designed the study and wrote the

protocol. Giulia Fioravanti, Sirio Ianni and Luca Montanelli conducted literature searchesand provided summaries of previous research studies. Giovanni Castellini and FrancescoRotella conducted the statistical analysis. Giulia Fioravanti and Carolina Lo Sauro wrotethe first draft of the manuscript and all authors contributed to and have approved thefinal manuscript.

Conflict of interestAll the authors declare the absence of any potential conflicts of interest, including spe-

cific financial interests and relationships and affiliations (other than those affiliationslisted on the title page of the manuscript) relevant to the subject of the manuscript.

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