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Journal of Adolescence
journal homepage: www.elsevier.com/locate/adolescence
Brief report
Classifying binge eating-disordered adolescents based on severity
levels
Antonios Dakanalis
a,b,∗
, Maria Assunta Zanetti
b
, Fabrizia Colmegna
c
,
Giuseppe Riva
d,e
, Massimo Clerici
a,c
a
Department of Medicine and Surgery, University of Milano Bicocca, Monza, Italy
b
Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
c
Department of Mental Health, San Gerardo Hospital, Monza, Italy
d
Department of Psychology, Catholic University, Milan, Italy
e
Applied Technology for Neuro-Psychology Laboratory, Istituto Auxologico Italiano, Milan, Italy
ARTICLE INFO
Keywords:
Binge-eating disorder
Severity
Psychopathology
Quality of life
Youth
ABSTRACT
The new severity criterion for binge-eating disorder (BED), introduced by the most recent (fifth)
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a means of
addressing within-group variability in severity, was tested in 223 Italian (13-18-year-old) ado-
lescents (86.1% females) with (DSM-5) BED presenting for treatment. Analyses revealed that
participants classified with mild (35.9% of the sample), moderate (38.1%) severe (13.4%), and
extreme (12.6%) severity of BED, based on their clinician-rated weekly frequency of binge-eating
(BE) episodes, were statistically distinguishable in physical characteristics (body mass index) and
a range of clinical variables regarding eating-related psychopathology and putative maintenance
factors, health-related quality of life, and mood and anxiety disorder comorbidity (medium-to-
large effect sizes). Between-group differences in age-at-onset of BED or demographics were not
detected. The findings provide support for the utility of BE frequency as a severity criterion for
BED in adolescence. Implications for future studies are discussed.
1. Introduction
Binge-eating disorder (BED), characterized by recurrent binge eating (BE) in the absence of extreme compensatory behaviours
(e.g., self-induced vomiting) is currently a formal eating disorder (ED) diagnosis in the DSM-5 (American Psychiatric Association
[APA], 2013), previously in the DSM
-IV appendix
(APA, 1994) as a research criteria set for further study. BED, traditionally considered
as an adult disorder, occurs in adolescence with some epidemiological evidence highlighting BED as the most prevalent ED in youth
(Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011). It has been identified in 1.6% of 13-18-year-old adolescents from the
community (Swanson et al., 2011), and in up to 20% of treatment-seeking adolescents (e.g., Dakanalis, Timko, Clerici, Riva, & Carrà,
2017; Goldschmidt et al., 2008). Similar to BED in adults, this disorder in adolescence is associated with medical complications
related to excess body weight, eating-related psychopathology (i.e., restraint, shape, weight, and eating concern), major forms of
psychiatric comorbidity (e.g., mood and anxiety disorders) and impairment of health-related quality of life (e.g., Kessler et al., 2013;
Pasold, McCracken, & Ward-Begnoche, 2014; Swanson et al., 2011; Tsappis, Freizinger, & Forman, 2016). Furthermore, several trans-
diagnostic factors (e.g., low self-esteem, interpersonal problems, perfectionism, body surveillance, mood intolerance) involved in the
http://dx.doi.org/10.1016/j.adolescence.2017.10.003
Received 17 February 2017; Received in revised form 4 October 2017; Accepted 9 October 2017
∗
Corresponding author. Department of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900, Monza, Italy.
E-mail address: antonios.dakanalis@unimib.it (A. Dakanalis).
Journal of Adolescence 62 (2018) 47–54
0140-1971/ © 2017 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
MARK
maintenance process of all EDs in adults, BED included (e.g., Dakanalis, Carrà, Calogero et al., 2015; Dakanalis, Clerici et al., 2016;
Dakanalis, Timko et al., 2016; Fairburn et al., 2009; Fitzsimmons-Craft, Bardone-Cone, & Kelly, 2011), appear to play a key role in the
persistence of BE pathology in youth (e.g., Allen, Byrne, & McLean, 2012; Boone, Soenens, Vansteenkiste, & Braet, 2012; Dakanalis,
Timko et al., 2017; Goldschmidt, Lavender, Hipwell, Stepp, & Keenan, 2017; Goldschmidt, Wall, Loth, Bucchianeri, & Neumark-
Sztainer, 2014; Ranzenhofer et al., 2014; Tsappis et al., 2016).
The female to male rate ratio is not only less skewed in BED (∼2:1 to 6:1) than in other EDs (e.g., Raevuori, Keski-Rahkonen, &
Hoek, 2014; Smink et al., 2014), but also “the presentation of BED has been shown to be similar in males and females”(Murray et al.,
2017, p. 4). Evidence suggests that young females and males with BED did not differ significantly in BE frequency, associated eating-
related psychopathology and (aforementioned) putative maintenance factors, accompanying mood and anxiety disorder comorbidity,
and impairment of health-related quality of life (e.g., Barry, Grilo, & Masheb, 2002; Dakanalis, Carrà, Clerici, & Riva, 2015;
Dakanalis, Favagrossa et al., 2015; Dakanalis & Riva, 2013a,b; Guerdjikova, McElroy, Kotwal, & Keck, 2007; Jambekar, Masheb, &
Grilo, 2003; Reas, Grilo, Masheb, & Wilson, 2005; Serino et al., 2016; Striegel, Bedrosian, Wang, & Schwartz, 2012; Udo et al., 2013).
Besides gender differences in metabolic dysfunctions and key biological factors (e.g., Klump, Culbert, & Sisk, 2017; Udo et al., 2013),
both genders also appear similar in terms of treatment response (e.g., Guerdjikova et al., 2014), as well as age-of-BED onset and body
mass index (BMI) (e.g., Striegel et al., 2012; Udo et al., 2013).
BED, like other threshold EDs (e.g., Dakanalis, Bartoli et al., 2016), varies in terms of symptom severity and treatment outcome,
and elucidation of factors accounting for this variation is of nosological and clinical significance (e.g., Dakanalis, Colmegna, Riva, &
Clerici, 2017; Masheb & Grilo, 2008; Picot & Lilenfeld, 2003). Notably, in addition to changing the minimum frequency and duration
of BE episodes “from two days per week over six months (DSM-IV stipulations) to once per week for three months”(Dakanalis, Riva,
Serino, Colmegna, & Clerici, 2017, p. 268), the DSM-5 (APA, 2013) added a new severity indicator (or specifier) based on BE frequency
to “address within-group variability and heterogeneity in severity and help clinicians to track patients' progress”(Dakanalis,
Colmegna et al., 2017, p. 917). Specifically, four severity groups based on the frequency of BE episodes were defined (APA, 2013)as
follows: extreme (> 14 episodes/week), severe (8–13 episodes/week), moderate (4–7 episodes/week), and mild (1–3 episodes/week).
The aforementioned DSM-5 severity groups of BED (APA, 2013) appear valid in terms of the significant between-group differences
observed in eating-related psychopathology (i.e., restraint, shape, weight, and eating concern) in a recent study performed with
treatment-seeking overweight adults with (DSM-5) BED (Grilo, Ivezaj, & White, 2015). Similar findings have been reported in two
more recent studies (Dakanalis, Colmegna et al., 2017; Dakanalis, Riva et al., 2017) performed with (independent) clinical samples of
adults diagnosed with (DSM-5) BED, which also revealed that the four DSM-5 severity groups of BED were statistically distin-
guishable in four putative maintenance factors (low self-esteem, interpersonal problems, perfectionism, and mood intolerance),
psychiatric and personality-disorder comorbidity, metabolic abnormalities and end-of-treatment abstinence from (i.e., no episodes of)
BE. Despite the (mentioned) fact that BED, which develops over adolescence, was identified in up to 20% of treatment-seeking
adolescents and research evidence for a significant association between BED severity and the proportion of community adolescent
cases with BED detected and treated by mental health care services (Smink et al., 2014), no research has to date evaluated the utility
of BE frequency as a severity indicator for BED in adolescents presenting for treatment. Thus, while existing research provides support
for the DSM-5 severity indicator of BED in adults, its clinical utility and validity in treatment-seeking youth remains to be seen.
This study tests the DSM-5 severity indicator for BED in adolescents with (DSM-5) BED presenting for treatment. Driven by the
empirical literature on BED mentioned above, we evaluated whether treatment-seeking adolescents sub-grouped based on the
aforementioned DSM-5 severity definitions (APA, 2013) would show significant differences in a range of variables (of clinical in-
terest) associated with BED and/or involved in the maintenance process of this condition, as recommended (e.g., Dakanalis,
Colmegna et al., 2017; Dakanalis, Riva et al., 2017; Grilo et al., 2015; Stice et al., 2001). These variables (assessed before adolescents
are triaged to a treatment programme) include eating-related psychopathology (i.e., restraint, shape, weight, and eating concern) and
five putative maintenance factors (i.e., low self-esteem, interpersonal problems, perfectionism, body surveillance, and mood intol-
erance), mood and anxiety disorder comorbidity, and health-related quality of life. Between-group differences in basic demographic
(i.e., age, ethnicity/race, and gender) and physical (i.e., BMI) characteristics and age-of-BED onset were also investigated. We ex-
pected that our participants classified with mild, moderate, severe and extreme severity of BED (based on the BE frequency, APA,
2013), would show meaningful differences in eating-related psychopathology, BMI, mood and anxiety disorder comorbidity, levels of
health-quality of life and scores on the measures of all putative maintenance factors considered. This hypothesis was based on the
already mentioned findings from recent studies that examined the utility of the DSM-5 severity indicator for BED in treatment-seeking
adults (see above) and prior adolescent research revealing positive associations between BE frequency and scores on the measures of
all putative maintenance factors considered (e.g., Allen et al., 2012; Boone et al., 2012; Dakanalis, Timko et al., 2017; Goldschmidt
et al., 2014, 2017; Ranzenhofer et al., 2014; Tsappis et al., 2016) and that more frequent BE was related to greater BMI, eating-related
and comorbid (mood and anxiety) psychopathology, and poorer health-quality of life (e.g., Dakanalis, Timko et al., 2014; Glasofer
et al., 2007; Goldschmidt et al., 2008; Isnard et al., 2003; Pasold et al., 2014; Tsappis et al., 2016). Between-group differences in age,
ethnicity/race, gender and age-of-BED onset were not expected, given prior findings with adolescents and adults highlighting that
different degrees of BE frequency are unrelated to the demographic characteristics considered and the age when BED first occurred
(e.g., Picot & Lilenfeld, 2003; Smink et al., 2014).
A. Dakanalis et al. Journal of Adolescence 62 (2018) 47–54
48
2. Methods
2.1. Participants
Participants were drawn from a sample of 1487 (13-18-year-old) adolescents consecutively referred (by family doctors and other
health professionals of the Italian National Health System) to, and assessed for treatment of an ED, at three medium to large spe-
cialized centres (sites)
1
(in Northern and Central Italy) for child and adolescent EDs between October 2011 and September 2016.
Though a portion of this data set has already been used to evaluate the role of objectified body consciousness (Dakanalis, Timko et al.,
2017) in ED psychopathology, there is no overlap between those results and the ones presented here. In this study, participants
meeting threshold DSM-5 (APA, 2013) BED diagnosis were included. Exclusion criteria included mental retardation or pervasive
developmental disorders (n= 2), severe psychiatric conditions (current substance use disorders and psychosis) that could inter-
ference with the assessment process (n= 2) or those influencing eating/body weight (e.g., thyroid problems, diabetes mellitus type 1,
pregnancy and lactation) (n= 4), any concurrent treatment for eating and/or weight-related problems, and insufficient proficiency
in Italian (n= 1). A total of 1255 subjects were excluded because they did not meet the other study eligibility criteria (i.e., DSM-5
criteria for threshold BED). The sample, invited to participate in the current inquiry, comprised 223 adolescents (86.1% [n= 192]
female, M
age
= 15.3 years, SD = 1.7) with (threshold) DSM-5 diagnosis of BED (APA, 2013); all of them agreed to participate (100%
response rate). BED diagnosis was judged by the experienced assessing clinician of each site according to the diagnostic items of the
Italian version (Mannucci, Ricca, Di Bernardo, & Rotella, 1996) of the Eating Disorder Examination-Interview-12.0D (EDE; Fairburn
& Cooper, 1993). In line with prior research, these EDE items were rated for DSM-5 duration stipulations (APA, 2013) and assessed
weekly frequency of (objective) episodes of BE, i.e., “consumption of an unambiguously large amount of food accompanied by loss of
control over eating”(Dakanalis, Riva et al., 2017, p. 269); inter-rater reliability for DSM-5 BED diagnosis (κ= 1.0) and intra-class
correlation coefficient for BE episodes (ICC = 1.0), examined in a 35% random sample (n= 78) based on audiotape ratings, were
excellent. Based on the responses to the EDE items regarding the frequency of BE episodes, 35.9% (n= 80) of the sample was
classified with mild, 38.1% (n= 85) with moderate, 13.4% (n= 30) with severe, and 12.6% (n= 28) with extreme severity of BED.
The average weekly frequency of BE (over the past three months) was 1.84 (SD = 0.42), 5.28 (SD = 0.64), 9.86 (SD = 0.92) and
14.85 (SD = 0.42) for adolescents with mild, moderate, severe, and extreme severity of BED, respectively.
2
2.2. Measures
The assessment of eating-related psychopathology included four attitudinal subscales yielded by the Italian version (Mannucci et al.,
1996) of the EDE-Interview-12.0D (Fairburn & Cooper, 1993) (time frame: past four weeks) –restraint, shape, weight and eating
concern; intra-class correlation coefficients, examined in a 35% random sample (n= 78) based on audiotape ratings, were.98-.1.00.
Higher scores on the EDE (self-explanatory) subscales indicate a greater manifestation of the particular construct measured.
The assessment of mood and anxiety disorder comorbidity was based on the Italian version (Kaufman, Birmaher, Rao, & Ryan, 2004)
of the Schedule for Affective Disorder and Schizophrenia for School-Age Children (Kaufman, Birmaher, Brent, Rao, & Ryan, 1996)–a
psychiatric diagnostic interview for children and adolescents. Inter-rater reliabilities (κ) for current anxiety and mood disorder
diagnoses, examined in a 35% random sample (n= 78) based on audiotape ratings, were .99–1.0.
As in prior ED research with adolescents (e.g., Pasold et al., 2014), the global scores of the Italian version (Conti, 2002) of the (23-
item) Pediatric Quality of Life Inventory-Version 4.0 (Varni, Seid, & Kurtin, 2001), measuring levels of physical, emotional, school
and social functioning, were used to assess health-related quality of life (α= 0.91); scores range from 0 to 100, with 0 meaning the
worst and 100 meaning the best levels of health-related quality of life.
The assessment of the putative maintenance factors included (a) selected composite or single scales of the Italian version (Garner,
2008) of the Eating Disorder Inventory-3 (Garner, 2004) for measuring mood intolerance or deficits in coping with aversive emo-
tional states (via the 8-item emotional dysregulation scale; α= 0.90), perfectionism (via the 6-item perfectionism scale; α= 0.88),
interpersonal problems (via the 14-item interpersonal problems composite scale; α= 0.89) and low self-esteem (via the 6-item low
self-esteem scale; α= 0.89), and (b) a selected subscale of the Italian version (Dakanalis, Timko et al., 2017) of the Objectified Body
Consciousness Scale (McKinley & Hyde, 1996) for measuring body surveillance or persistent thinking and habitual monitoring of
one's body (via the 8-item body surveillance subscale scale; α= 0.88). Higher (single/composite) scale or subscale scores indicate a
greater manifestation of the particular construct measured.
Basic demographic (i.e., age, gender, and ethnicity/race) and physical (i.e., BMI) characteristics and other information, e.g. age-of-
BED onset (determined by specified clinician-rated items; see Swanson et al., 2011, for further details) obtained at the (face-to-face)
interview assessment are considered in the planned analyses. BMI was calculated by dividing the weight (in kg) by height squared (in
metres), which were collected (at each site) with standard calibrated electronic instruments in the fasting state with minimal clothing
and shoes removed (e.g., Dakanalis, Carrà et al., 2016); in line with prior ED research in adolescents (e.g., Glasofer et al., 2007;
Goldschmidt et al., 2008) the standard-deviation score of BMI (BMI-SDS) based on age- and sex-specific BMI Italian reference data
(Cacciari et al., 2006) is reported.
1
The specialist ED centres/sites are: Brescia Civil Hospital, San Raffaele Hospital of Milan, Agostino Gemelli Teaching Hospital of Rome.
2
Analysis of variance revealed that the four severity groups differed significantly in BE frequency (F
(3,219)
= 3820.97, p< 0.001), as expected given the method
used to create the DSM-5 severity categories/groups of BED (APA, 2013).
A. Dakanalis et al. Journal of Adolescence 62 (2018) 47–54
49
2.3. Procedure
As in prior ED research with adolescents (e.g., Dakanalis, Carrà et al., 2016), participants completed a battery of selected self-
reported questionnaires (which took approximately 40 min) at the end of the diagnostic assessment, carried out with clinical in-
terviews (see Participants and Measures) by clinicians with almost 15 years' experience in assessing and treating adolescent EDs. The
standardized self-reported questionnaires (see Measures) for 13-18-year-old adolescents (completed all at once) were administered in
counterbalanced order to offset possible ordering effects (e.g., Dakanalis, Carrà et al., 2016). Written informed consent and assent,
respectively, were obtained from all participants and parents of adolescents after all study procedures were fully explained and before
participants were being triaged to a treatment programme. The study was approved by the ethics review board of each local in-
stitution (site) and the co-ordinating body of the project (University of Pavia) and carried out in accordance with the Declaration of
Helsinki of 1975, as revised in 2008.
2.4. Statistics
Differences in all study variables between the four (mild, moderate, severe, and extreme) severity groups of BED were assessed in
SPSS 21.0 (IBM, NY) by the χ
2
test or ANOVA, as appropriate, followed by post-hoc pairwise comparisons with Bonferroni correction
if needed (Reid, 2014); there were no missing data. The appropriate measures of effect size for categorical (Cramer's φ) and con-
tinuous (partial η
2
) variables were calculated (Reid, 2014) and reported.
3. Results
As shown in Table 1 summarising descriptive statistics and analyses comparing the severity groups (including measures of effect
size and cut-offconventions) on all study variables,
3
the mild, moderate, severe, and extreme severity groups of BED were statistically
indistinguishable only in demographics and the age-of-BED onset. The extreme severity group featured significantly poorer health-
related quality of life, greater eating-related psychopathology (assessed by the four EDE subscales), and higher mean BMI-SDS, rates
of (current) comorbid (mood and anxiety) disorders and scores on the measures of putative maintenance factors (low self-esteem,
interpersonal problems, perfectionism, body surveillance, and mood intolerance) as compared with the severe, moderate, and mild
severity groups of BED, which also differed significantly from each other.
4. Discussion
For the first time, this study evaluated the new DSM-5 severity indicator for BED in 223 adolescents with DSM-5-defined BED
(APA, 2013) presenting for treatment. Participants were classified with mild (35.9%), moderate (38.1%), severe (13.4%), and ex-
treme (12.6%) severity of BED, based on their clinician-rated BE frequency, and compared on a range of variables of clinical interest,
demographic and physical characteristics. Rates of each severity group in the current inquiry were similar to those for treatment-
seeking adults with DSM-5 BED (e.g., Dakanalis, Colmegna et al., 2017). In line with our (empirically-driven) expectations (see
introduction), the mild, moderate, severe, and extreme severity groups of BED were found to significantly differ from each other in
mood and anxiety disorder comorbidity, eating-related psychopathology (i.e., restraint, shape, weight, and eating concern) and
putative maintenance factors (low self-esteem, interpersonal problems, perfectionism, and mood intolerance), with significantly
higher levels/rates across the severity groups. While these findings parallel what has been observed in recent studies examining the
utility of the DSM-5 severity indicator for BED in adults (Dakanalis, Colmegna et al., 2017; Dakanalis, Riva et al., 2017; Grilo et al.,
2015), there was also evidence that the study severity groups of BED significantly differ from each other in body surveillance (i.e., an
additional putative maintenance factor considered in this study) and physical characteristics (BMI-SDS), with significantly higher
levels across the severity groups. Additionally, they were statistically distinguishable in health-related quality of life, with sig-
nificantly lower levels across the severity groups. The latter results were not unexpected and are consistent with earlier adolescent
and adult research indicating that more frequent BE was related to greater body surveillance, higher mean BMI (or BMI-SDS), and
poorer health-related quality of life (e.g., Dakanalis, Carrà, Timko et al., 2015; Dakanalis, Clerici et al., 2016; Dakanalis, Timko et al.,
2017; Pasold et al., 2014; Pla-Sanjuanelo et al., 2015; Striegel et al., 2012; Tsappis et al., 2016). The absence of differences in basic
demographics (i.e., age, ethnicity/race, and gender) and age-of-BED onset between the four (mild, moderate, severe, and extreme)
severity groups of BED is also consistent with our expectations and prior BED research in adults and adolescents showing that
different degrees of BE frequency are unrelated to demographic characteristics considered and the age when BED first occurred (e.g.,
Picot & Lilenfeld, 2003; Smink et al., 2014), lending some credence to the suggestion that “age-at-onset is probably more disorder-
than severity-dependent”(Smink et al., 2014, p. 616).
The significant differences observed between the mild, moderate, severe, and extreme groups of BED in eating-related psycho-
pathology (i.e., restraint, shape, weight, and eating concern), BMI-SDS, health-related quality of life, mood and anxiety disorder
3
Since preliminary analyses did not detect any significant differences (data not shown) among the three specialist ED centres/sites sites (where data were collected)
and between female and male participants in any study variable considered (and displayed in Table 1), as well as in frequency of BE episodes (used to classify our
participants into the four DSM-5 severity groups of BED, see Participants subsection), the results that follow are not stratified by site and/or gender. Due to space
restrictions, the results of the analyses summarized here are available to interested readers on request from the corresponding author.
A. Dakanalis et al. Journal of Adolescence 62 (2018) 47–54
50
Table 1
Comparison of participants with binge-eating disorder (N = 223) across DSM-5 severity groups.
Variable Mild (n= 80) Moderate (n= 85) Severe (n= 30) Extreme (n= 28) F
(3,219)
χ
2
(3)
pη
2
φ
Age (years)
a
,M(SD) 15.49 (1.56) 14.99 (1.94) 15.42 (1.60) 15.22 (1.74) 1.23 0.298
Gender (female)
a
,n(%) 70 (87.5) 72 (84.7) 26 (86.7) 24 (85.7) 0.28 0.964
Ethnicity/Race (white)
a
,n(%) 77 (96.3) 81 (95.3) 29 (96.7) 27 (96.4) 0.17 0.982
Age-of-BED onset (years)
a
,M(SD) 12.92 (1.59) 12.88 (1.31) 13.22 (1.37) 13.06 (1.34) 0.57 0.637
Body mass index–standard deviation score
a,b
,M(SD) 0.77 (0.73) 1.02 (0.44) 1.67 (0.70) 2.09 (0.40) 37.52 < 0.001 0.24
EDE–Restraint (score range: 0–6)
a,b
,M(SD) 0.88 (0.72) 1.22 (0.89) 1.77 (1.13) 2.48 (0.80) 27.10 < 0.001 0.17
EDE–Eating Concern (score range: 0–6)
a,b
,M(SD) 1.13 (0.71) 1.75 (1.03) 2.39 (1.11) 3.24 (1.23) 37.16 < 0.001 0.24
EDE–Shape Concern (score range: 0–6)
a,b
,M(SD) 2.03 (1.02) 2.72 (1.39) 3.49 (1.02) 4.33 (0.33) 33.58 < 0.001 0.21
EDE–Weight Concern (score range: 0–6)
a,b
,M(SD) 1.99 (1.01) 2.74 (1.40) 3.51 (1.04) 4.28 (0.40) 33.52 < 0.001 0.21
Current Anxiety Disorders
a,b
,n(%) 0 (0.0) 8 (9.4) 9 (30.0) 18 (64.3) 69.00 < 0.001 0.46
Current Mood Disorders
a,b
,n(%) 1 (1.3) 10 (11.8) 10 (33.3) 19 (67.9) 68.60 < 0.001 0.45
Pediatric Quality of Life Inventory (score range: 0–100)
a,b
,M (SD) 69.90 (10.1) 60.20 (10.8) 51.10 (10.2) 40.30 (7.3) 68.99 < 0.001 0.48
EDI3–Low Self-Esteem (score range: 0–24)
a,b
,M(SD) 6.11 (4.40) 7.83 (3.70) 10.22 (5.05) 14.18 (2.28) 30.37 < 0.001 0.19
EDI3–Perfectionism (score range: 0–24)
a,b
,M(SD) 5.99 (4.01) 7.92 (5.00) 10.57 (3.03) 12.70 (2.89) 21.41 < 0.001 0.12
EDI3–Emotional Dysregulation (score range: 0–32)
a,b
,M(SD) 6.69 (5.40) 11.88 (7.51) 17.44 (6.01) 25.55 (3.00) 72.14 < 0.001 0.51
EDI3–Interpersonal Problems (score range: 0–56)
a,b
,M(SD) 18.50 (6.55) 21.13 (6.02) 27.14 (8.66) 33.63 (9.03) 37.50 < 0.001 0.24
OBCS-Body Surveillance (score range: 1–7)
a,b
,M (SD) 1.89 (1.55) 2.64 (1.66) 3.54 (0.90) 4.41 (0.55) 25.11 < 0.001 0.16
Note. BED = Binge-Eating Disorder; EDE = Eating Disorder Examination; EDI3 = Eating Disorder Inventory-3; OBCS = Objectified Body Consciousness Scale.
a
Differences for continuous and categorical variables among the severity groups were assessed by means of ANOVA and χ
2
test [df (3, N= 223)], respectively. The appropriate measures of effect size for continuous (partial η
2
)
or categorical (Cramer's φ) variables are reported. Cut-offconventions for partial η
2
are as follows: small (0.01–0.09), medium (0.10–0.24), and large (≥0.25) (Reid, 2014). Cut-offconventions for Cramer's φ(with df = 3) are as
follows: small (0.06–0.16), medium (0.17–0.28), and large (≥0.29) (Reid, 2014).
b
All severity groups differed statistically in post-hoc pairwise comparisons (with Bonferroni correction) at p< 0.008 or less (Reid, 2014).
A. Dakanalis et al. Journal of Adolescence 62 (2018) 47–54
51
comorbidity, and five putative maintenance factors (body surveillance, low self-esteem, interpersonal problems, perfectionism, and
mood intolerance) considered speak directly to the concurrent validity of the DSM-5 severity indicator for BED. Nevertheless, the
magnitude of the detected differences was not comparable, suggesting that some of the mentioned variables provide more clinically
meaningful and useful information than others (e.g., Reid, 2014). The effect sizes for the observed between-group differences in
restraint (0.17) shape (0.21), weight (0.21), and eating concern (0.24), interpersonal problems (0.24), body surveillance (0.16),
perfectionism (0.12), low self-esteem (0.19) and BMI-SDS (0.24) were in the moderate range. Conversely, the effect sizes for the
observed between-group differences in mood intolerance (0.51), health-related quality of life (0.48) and mood (0.45) and anxiety
(0.46) disorder comorbidity, were large, highlighting these variables as salient targets in BED treatment (e.g., Dakanalis & Clerici,
2017; Tsappis et al., 2016). In absolute terms, mood intolerance was the primary variable distinguishing the severity groups. This
finding seems to be in accordance with maintenance (i.e., the trans-diagnostic cognitive-behavioural) models developed for adults
(for a description, see Dakanalis, Carrà, Calogero et al., 2015) and validated for youth (e.g., Allen et al., 2012) underscoring the key
role of emotion-regulation difficulties in BE. It also seems to concur with ecological momentary assessment and longitudinal research
implying that BE serves as a self-regulation strategy for negative emotional states and addressing maladaptive coping in response to
and/or cognitive-behavioural patterns eliciting these states may reduce the persistence and/or frequency of BE (e.g., Allen et al.,
2012; Dakanalis, Pla-Sanjuanelo et al., 2016; Goldschmidt et al., 2014, 2017; Haedt-Matt & Keel, 2011).
Overall, this study conducted with 223 adolescents with DSM-5 BED presenting for treatment provides support for the DSM-5
severity indicator for BED based on BE frequency (APA, 2013). Limitations of the current study include the reliance on self-report
assessment (for some study variables), the cross-sectional study design that precludes evaluation of the predictive validity of the DSM-
5 severity approach (APA, 2013) and the small sample of boys (n= 31). It is worth noting, however, that the female-to-male gender
ratio of BED observed in this study (∼6:1) is within the magnitude of the gender difference found in the epidemiological research
(e.g., Raevuori et al., 2014; Smink et al., 2014) and the size of our male sample with BED presenting for treatment (13.9% of the total
sample) is within recent estimated portions (∼10–15%) of young males (e.g., Dakanalis & Riva, 2013a; Forrest, Smith, & Swanson,
2017) presenting for BED treatment (for a recent discussion of treatment-seeking barriers, see Forrest et al., 2017). Despite this and
the fact that the whole study sample size (N= 223) was larger than that used by prior adult research to examine differences in
clinical variables between the four DSM-5 severity groups (e.g., Dakanalis, Colmegna et al., 2017; Dakanalis, Riva et al., 2017),
replication of the findings with larger adolescent clinical samples with BED and other methods of data collection (e.g., ecological
momentary assessment) and extension to different samples (i.e., community-recruited young people with BED), would be beneficial.
In addition to comparing the DSM-5 severity approach with alternative ones (i.e., subtyping based on overvaluation of shape/weight
or along dietary and negative/depressive affect dimensions; Masheb & Grilo, 2008; Stice et al., 2001), future studies should also track
severity fluctuation across time and test whether the DSM-5 severity groups of BED (APA, 2013)differ in additional clinical correlates
and socio-demographic variables (not considered here) such as parental educational, socio-economic status and family structure/
context and functioning, child abuse, psychiatric history, externalizing psychopathology, reward from high-calorie food intake and
behavioural impulse control (e.g., Caslini et al., 2016; Hamilton et al., 2015; Tsappis et al., 2016). It is also essential that future BED
research examines the DSM-5 (mild, moderate, severe, and extreme) severity groups of BED (APA, 2013) in terms of their prognostic
significance for treatment outcome, as this will provide evidence for the predictive validity of the DSM-5 (not evaluated in this study).
This aspect is particularly relevant in the light of recent meta-analytic evidence that pre-treatment rates of BE frequency are pre-
dictive of treatment outcome (Vall & Wade, 2015), i.e., BE remission. As already noted in the introduction, adult patients with BED
sub-grouped based on the DSM-5 severity definitions (APA, 2013) showed meaningful differences in BE remission (Dakanalis,
Colmegna et al., 2017) at the end of evidence-based treatment, i.e., manual-based cognitive-behavioural therapy (CBT). If, in future
research, adolescents with mild, moderate, severe and extreme severity of BED show a differential response to therapy (CBT and/or
treatment other than CBT; Tsappis et al., 2016), this will provide evidence for the predictive validity of the DSM-5 severity indicator
in youth, which is currently lacking. It will also be informative for promoting more appropriate treatment “for severe-to-extreme
BED, since this should differ from treatment regimens for mild-to-moderate presentations”(Dakanalis & Clerici, 2017, p. 841).
Acknowledgments
This research received no specific grant from any funding agency, commercial or not for-profit sectors and the authors declare
that they have no conflicts of interest. Special appreciation is expressed to all participants and the clinical staffof all Italian specialist
ED centres/sites for their help in the acquisition of data.
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