Momentary emotion surrounding bulimic behaviors in women with bulimia nervosa and borderline personality disorder

https://doi.org/10.1016/j.jpsychires.2012.08.014Get rights and content

Abstract

Background

Bulimia nervosa (BN) and borderline personality disorder (BPD) are disorders that involve emotion dysregulation, for negative emotion in particular, as well as impulsive behaviors beyond binge eating and vomiting. Given these similarities in psychopathology, it is not surprising that those with BN also present with BPD in approximately one third of cases. Improved understanding of similarities and differences in the experience of negative and positive emotion could aid in the development of treatments specifically tailored to the needs of these disorders.

Methods

In this study, we examined Ecological Momentary Assessment (EMA) data from 133 women diagnosed with BN, 25 of whom also exhibited diagnostic levels of BPD. Emotions and behaviors were assessed daily, with multiple random and event-contingent signals to complete questionnaires on portable digital devices, for a period of two weeks.

Results

Results indicated that the BPD group experienced higher negative emotional variability on bulimic event days. Both groups also demonstrated increasing negative emotion and decreasing positive emotion pre- binge eating and vomiting, with levels of negative emotion decreasing and positive emotion increasing after, for both behaviors.

Conclusions

In terms of group differences, additive effects were found for the BN comorbid with BPD group, who demonstrated greater negative emotional variability, on bulimic event days, and also had higher overall levels of negative emotion pre- and post-binge eating. Those with BN only, however, displayed increasing trajectories of positive emotion before and after binge eating and after vomiting, indicating a potential emotional dampening effect of BPD.

Section snippets

Emotion dysregulation in bulimia nervosa and borderline personality disorder

Over the last decade research has identified that emotion dysregulation plays a major role in the propagation and maintenance of both BN and BPD symptomatology. Emotion dysregulation refers to the inability to control and modulate one's affective state to such a degree that emotions are experienced as out of control (Shedler and Westen, 2004). Interestingly, many people with BN exhibit emotional dysregulation and impulsive behaviors (beyond binge eating and vomiting), even without a

Emotional impact of dysregulated eating behaviors

Emotion regulation models of dysregulated eating behaviors suggest that binge eating and vomiting occur following increasing levels of negative emotion, and that the behavior results in a decrease in negative emotion (Selby et al., 2008). These functions are supported by numerous cross-sectional studies on binge eating and vomiting (Agras and Telch, 1998; Lynch et al., 2000) as well as longitudinal ecological momentary assessment studies (Anestis et al., 2010; Smyth et al., 2007). Binge eating

Binge eating versus vomiting

In general, trajectories of emotion prior to and after binge eating and vomiting have been studied with relatively the same expectations, increasing negative emotion before and decreased negative emotion afterward (Smyth et al., 2007). Yet, few studies have actually looked at potential differences in the quality of emotion surrounding these behaviors separately. Binge eating and vomiting are highly related behaviors, yet they are also fundamentally distinct and as such they may arise in

Current study

Various aspects of mood and behavior have been examined in eating disordered and personality disorder samples using ecological momentary assessment (EMA; Stone and Shiffman, 1994). EMA is a relatively new and innovative way to collect data that partially circumvents the limitations inherent to self-report measures, as it reduces retrospective recall bias while also allowing for assessment in a natural setting. A number of studies implementing EMA in the areas of eating disorders and BPD have

Methods

Participants were 133 adult females who were recruited from the community and who met criteria for BN (assessment procedure described below). Women were either referred for the study by their physicians, eating disorder treatment providers, or self-referred via community flyers. All completed a telephone screen to confirm eligibility prior to in-person assessment (i.e., inclusion criteria: female, age ≥ 18, meets DSM-IV criteria for BN, no changes in mental health treatment in past 6 weeks).

Procedures

The current research was approved by the Institutional Review Boards at the University of North Dakota and MeritCare Medical Center. During the baseline assessment, participants provided written informed consent and completed a baseline assessment to ensure eligibility. Next participants were trained in the use of a digital monitoring device (PalmPilot™ Vx). Participants then followed the assessment protocol for two days of practice, during which time they were asked to record just as they

Preliminary analyses

Participants had a mean age of 25.3 years (SD = 7.6; range = 18–55), were predominantly Caucasian (97.0%), and single/never married (76.8%). Most were well-educated, with 99.2% having completed high school and 82.0% having completed at least some college. The mean body mass index (BMI; kg/m2) for the sample was 23.9 (SD = 5.2; range = 17.1–47.6), which is considered to be in the normal range.

The validity of the use of the DIB-R 2 Year Total score to estimate BPD diagnoses was supported by a

Discussion

BN and BPD are disorders that are frequently comorbid and they share many similarities in emotion dysregulation and impulsive behavior. The purpose of this study was to establish differences in overall emotional variability and emotional responses before and after binge eating and vomiting between those with BN and comorbid BPD. Using data from an EMA study, we compared women with BN and no BPD diagnosis (BN−BPD) to those with BN and comorbid BPD (BN + BPD) on variability of negative and

Role of funding source

This research was supported by the National Institute for Mental Health R01-MH-59674 (Dr. Wonderlich) and NRSA T32 MH 082761; Dr. Le Grange, Site Director. Dr. Le Grange receives royalties from Guilford Press, and honoraria from the Training Institute for Child and Adolescent Eating Disorders, LLC.

Contributors

Edward A. Selby contributed to the conceptualization of the manuscript, running of analyses, and wrote and revised significant portions of the manuscript.

Peter Doyle conceptualized the manuscript, contributed to initial data analysis, and composition of the preliminary draft of the manuscript.

Ross Crosby contributed to data analysis of the paper and construction to tables and graphs.

Stephen Wonderlich, Scott Engel, James Mitchell, and Daniel Le Grange all contributed to data collection for the

Conflicts of interest

The authors report no conflicts of interest.

Acknowledgments

None.

References (41)

  • C.G. Fairburn et al.

    The eating disorder examination

  • M.B. First et al.

    The Structured Clinical Interview for DSM-IV Axis I Disorders – Patient Edition (SCID/P)

    (1995)
  • M.B. First et al.

    Structured Clinical Interview for DSM-IV Axis II personality disorders (SCID-II)

    (1997)
  • K. Godt

    Personality disorders in 545 patients with eating disorders

    European Eating Disorders Review

    (2008)
  • C.G. Greeno et al.

    Binge antecedents in obese women with and without binge eating disorder

    Journal of Consulting and Clinical Psychology

    (2000)
  • M. Klein et al.

    The Wisconsin Personality Disorders Inventory: development and psychometric characteristics

    Journal of Personality Disorders

    (1993)
  • E.D. Klonsky

    What is emptiness? Clarifying the 7th criterion for borderline personality disorder

    Journal of Personality Disorders

    (2008)
  • H.W. Koenigsberg et al.

    Characterizing affective instability in borderline personality disorder

    American Journal of Psychiatry

    (2002)
  • D. Le Grange et al.

    Does momentary assessment detect binge eating in overweight women that is denied at interview?

    European Eating Disorders Review

    (2001)
  • M.M. Linehan

    Cognitive-behavioral treatment for borderline personality disorder

    (1993)
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