The emotional eating scale: The development of a ...

The Emotional Eating Scale: The Development of a Measure to Assess Coping with Negative Affect by Eating

Bruce Arnow Justin Kenardy W. Stewart Agras (Accepted 19 April 1994)

The development of the Emotional Eating Scale (EES) is described. The factor solution replicated the scale’s construction, revealing AngerlFrustration, Anxiety, and Depression subscales. All three subscales correlated highly with measures of binge eating, providing evidence of construct validity. None of the EES subscales correlated significantly with general measures of psychopathology. With few exceptions, changes in EES subscales correlated with treatment-related changes in binge eating. In support of the measure’s discriminant efficiency, when compared with obese binge eaters, subscale scores of a sample of anxiety-disordered patients were significantly lower. Lack of correlation between a measure of cognitive restraint and EES subscales suggests that emotional eating may precipitate binge episodes among the obese independent of the level of restraint. The 25-item scale is presented in an Appendix (Arnow, B., Kenardy, I., & Agras, W.S.: lnternational]ournal of Eating Disorders, 17, 00-00,1995). 0 1995 by John Wiley & Sons, Inc.

As Polivy and Herman (1993) have noted, stress and negative mood are the most frequently cited precipitants of binge eating (e.g., Abraham & Beumont, 1982; Arnow, Kenardy, & Agras, 1992; Heatherton & Baumeister, 1991; Herman & Polivy, 1975; Lingswiler, Crowther, & Stephens, 1989; Ruderman, 1985). Yet our knowledge of the relationship between negative mood and overeating is limited, particularly among the obese.

Bruce Arnow, Ph.D., is Assistant Professor of Psychiatry and Chief of the Psychology Service at the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California. JustinKenardy, Ph.D., i s Senior Lecturer i n Psychology at the University of Newcastle in New South Wales, Australia. W. Stewart Agras, M.D., i s Professor of Psychiatry and Director of the Behavioral Medicine Program at the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California. Address reprint requests to Bruce Arnow, Ph. D., Department of Psychiatry, Behavioral Medicine Program, Stanford University School of Medicine, Stanford, CA 94305-5542. lnternationallournal o f Eating Disorders, Vol. 18, No. 1, 79-90 (1995) 0 1995 by John Wiley & Sons, Inc.

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There are several reasons for this. First, conceptual models guiding research and treatment of the obese have often assigned emotional eating a peripheral role. The internal-external theory of obesity, formulated by Schachter (1968, 1971), proposed that compared with normals, the obese would demonstrate increased responsiveness to salient environmental food cues. As the obese were viewed as less responsive to internal stimuli in general, emotional distress lacked a significant role in this model (Schachter, Goldman, & Gordon, 1968). Nisbett’s set point theory (1972) suggested that the obese have a higher than average ideal weight; attempting to conform to cultural norms, they eat less than their body physiologically requires. The consequent deprivation was assumed to have several effects including increased responsiveness to environmental food cues, as well as heightened emotionality. In this case, however, emotional lability associated with eating was considered an epiphenomenon rather than a factor worthy of investigation in its own right. Restraint theory (Herman & Mack, 1975; Herman & Polivy, 1980; Polivy & Herman, 1985), which incorporated Nisbet’s emphasis on the role of dieting, suggests that attempts to maintain one’s eating well below the level necessary for satiety occasion a state of physiological deprivation predisposing the individual to counterregulatory eating under a variety of circumstances. The restraint model has generated a considerable amount of research including several laboratory studies of the interaction between negative mood and restrained eating (e.g., Cools, Schotte, & McNally, 1992; Herman & Polivy, 1975; Herman, Polivy, Lank, & Heatherton, 1987; Ruderman, 1985; Steere & Cooper, 1993), but for a variety of reasons including the secrecy associated with emotional eating and variability in subjects‘ food preferences (Ganley, 1989) the relevance of such studies to understanding the eating patterns of the obese is questionable. Furthermore, negative mood, while an important factor in this model, is conceptualized as secondary to restraint, one of many conditions including alcohol consumption and food rule violations, under which disinhibition or binge eating might occur. A second reason for the relative lack of attention to the relationship between negative mood and binge eating among the obese is that much of the interest in binge eating among investigators was concentrated upon bulimics and anorexics (Arnow et al., 1992; Marcus & Wing, 1987; Marcus, Wing, & Hopkins, 1988). Though Stunkard (1959) first identified binge eating as a potentially important factor in obesity over 30 years ago, with few exceptions (e.g., Hudson & Williams, 1981; Leon & Chamberlain, 1973a, 197310; Slochower & Kaplan, 1980)references to binge eating among the obese were confined to the clinical literature (Bruch, 1973; Buchanon, 1973; Crisp, 1967; Kornhaber, 1970; Wolman, 1982), until the early 1980s when the prevalence of binge eating among the obese began to become more systematically documented (Gormally, Black, Daston, & Rardon, 1982; Keefe, Wyshogrod, Weinberger, & Agras, 1984; Lor0 & Orleans, 1981; Marcus & Wing, 1987; Marcus, Wing, & Lamparski, 1985; Marcus et al., 1988; Telch, Agras, & Rossiter, 1988). Noting the lack of attention to emotional eating among the obese, Lowe and Fisher (1983) speculated that because emotional eating was often described in psychoanalytic terms, the scientific community was less inclined to pursue its significance (p. 147). Not surprisingly, few self-report instruments exist to assess emotional eating in the obese. Among those we have, few have a sufficient number of items to enable a detailed analysis of the potentially distinctive relationships between specific negative mood states and disinhibited eating. The Three Factor Eating Questionnaire (TFEQ; Stunkard & Messick, 1985) was originally presented with a scale assessing Disinhibition in addition to scales measuring Dietary Restraint and Perceived Hunger. However, in a large (N

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= 442) factor analytic investigation of the TFEQ, Ganley (1988) reported that Disinhibition was best described by two factors, one assessing Weight Lability and the other, Emotional Eating. But the latter has only six items, and Ganley noted the need for expansion (p. 645). Furthermore, the true-false format employed in the TFEQ (Stunkard & Messick, 1985) has several limitations including placing the respondent in a situation in which neither choice is valid all of the time and enhancing tendencies toward responding in socially desirable ways (Mason & Bramble, 1978). The Dutch Eating Behaviour Questionnaire (DEBQ; van Strien, Frijters, Bergers, & Defares, 1986) has an emotional eating scale in addition to scales assessing restraint and externality. The DEBQ’s 13-item emotional eating scale comprises two factors, one dealing with eating in response to diffuse emotions, and the other assessing eating in the presence of clearly labeled emotions. While the DEBQ facilitates a more detailed analysis of emotional eating than the TFEQ (Stunkard & Messick, 1985), it does not permit distinctions in the relationship between specific mood states (e.g., anger, anxiety, depression) and overeating. The common practice of referring generically to “negative mood’ and its relation to overeating may reflect an absence of measures to facilitate sufficiently detailed distinctions rather than substantial evidence that all varieties of negative mood precipitate disinhibited eating in the same way. Indeed, several studies have suggested otherwise. For example, Steere and Cooper (1993) reported that restrained eaters’ consumption following an anxiety induction procedure was unaffected when levels of perceived hunger were low and was reduced when perceived hunger was high. They concluded that the assumption that ”dietary restrainers as a group experience anxiety as disinhibitory of eating may not be entirely accurate” (p. 218). In a descriptive study of binge eaters (Arnow et al., 1992), we reported that subjects described angedfrustration prior to a binge 42% of the time, but sadness/depression only 16% of the time. And Eldredge, Agras, and Arnow (in press) found that subjects who reported overeating predominantly in response to anger and depression gained significantly more weight between baseline and entry into a treatment program for binge eating and weight loss than did subjects who reported overeating in response to anxiety. The latter group actually decreased in weight while the former two groups both increased. The aim of the current study was to develop a questionnaire that would permit a more detailed analysis of the relationship between negative mood and disordered eating. We refer to the instrument as the Emotional Eating Scale (EES).

DESIGN OVERVIEW The aim of Study 1 was to develop items for the EES and to examine its psychometric properties, including its internal consistency, test-retest reliability, and its factor structure. The aim of Study 2, in addition to replicating the study of the psychometric qualities of the EES, was to assess its construct and criterion validity. Study 3 focused on the discriminant efficiency of the EES. Study 1

The goal of Study 1 was to develop the item pool for the EES and to investigate its psychometric properties.

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Item Development

In developing the scale, we employed a Likert-type format to assess the intensity of the relationship of mood to eating. The five-point scale used was anchored on ”no desire to eat” and “an overwhelming urge to eat,” with “a small desire to eat,” “a moderate desire to eat,’’ and ”a strong desire to eat” at the intermediate points. In a previous study (Arnow et al., 1992) of 19 obese binge eating females, we reported that feelings of anger/frustration, anxiety, and sadness/depression accounted for 95% of the antecedent moods reported by respondents with approximate proportions of 2:2:1. We used 21 items drawn from actual responses in that study, and added 4 items from the Profile of Mood States (McNair, Lorr, & Droppleman, 1971) to bring the total number of items to 25 while maintaining the relative proportions found in the original study. Method

Subjects

The 25-item EES was administered to 47 obese females who had been accepted into a treatment study targeting both binge eating and weight loss. Each subject met DSM-111-R criteria for bulimia nervosa with one exception, namely an absence of purging behavior. Thus during an initial screening interview each subject reported: (1)recurrent episodes of binge eating in which she perceived herself to consume a large amount of food in a short period of time, (2) a perceived lack of control or inability to stop eating during the binge episode, (3) an average of two or more binge episodes per week for the past 6 months, and (4) marked distress associated with binge eating. Subjects were excluded from study participation during the prescreening for the following reasons: (1)age below 18 or above 65; (2) current or past history of self-induced vomiting, laxative use, or other purging behavior; (3) current use of antidepressant medication or appetite suppressants; (4) concurrent treatment for weight loss or binge eating; (5) concurrent DSM-111-R diagnosis of unipolar or bipolar affective disorder with significant suicidal ideation, psychosis, drug abuse, or alcoholism. Subjects in this cohort had a mean age of 44.9 (SD = 10.4, range 23-64). Subjects mean body mass index (BMI), defined as weight in kilograms divided by the square of the height in meters, was 37.9 (SD = 6.0, range 26.1-51.7). Procedure

Subjects were administered the questionnaire following their initial diagnostic interview for the study. Questionnaires were readministered 2 weeks later at an appointment in which subjects were asked to fill out a number of other measures related to their presenting symptoms. Results

All items were subjected to a principal components analysis with a varimax rotation. Using a scree-test and simple structure criteria, three factors were extracted. Mean squared multiple correlation was 0.67, indicating adequate coverage of variance. An orthogonal rotation was used since there was very little between-factor correlation with oblique rotation. The factor structure is presented in Table 1. The first factor had loadings from 11 items.’ Examination of these items revealed that this factor contained the

1. One item “Inadequate” was originally viewed as an ”anxiety” item but instead factored on the anger/ frustration factor.

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original anger and frustration items. This factor accounted for 19.7%of the variance. The second factor had loadings for nine items accounting for 12.5% of the variance; this factor reflected the original anxiety items. The third factor loaded for five items and accounted for 10.4%of the variance. The loadings on this factor involved the depression items. Thus the factor solution replicated the construction of the scale. Three subscales were derived from the factor structure by summing the items that loaded on the factors. The mean for the AngerRrustration subscale was 23.96 (SD = 7.94), the mean for Anxiety was 15.19 (SD = 6.51), and for Depression the mean was 12.00 (SD = 4.00). Measures of internal consistency were calculated for the total scale and each of the factors. Coefficient alpha for the total scale was .81 indicating acceptable internal consistency. For the AngerIFrustration, Anxiety, and Depression subscales coefficient alphas, respectively, were .78, .78 and .72. Corrected item-total correlations were also calculated for each subscale. Examination of these indicated little support for the removal of any item from within the subscales (AngedFrustration .27-.58, Anxiety .32-.67, Depression .37-.58). Examination of the 2-week test-retest correlation of the scale total score indicated adequate temporal stability (r = .79, p < .OOl). Study 2

The aim of Study 2 was to assess the construct, discriminant, and criterion validity of the EES. Method Subjects

Subjects were 51 obese females who had been accepted into a treatment study for binge eating and weight loss. All subjects met the DSM-111-R criteria for bulimia nervosa Table 1. Rotated factor matrix Factor I Discouraged Guilty Irritated Angry Furious Inadequate Helpless Resentful Frustrated Jealous Rebellious Jittery On edge Shaky Nervous Excited Uneasy Worried Upset Confused Lonely Bored Sad Blue Worn out

.67 .65 .62 .60 .59 .57 .55 .53 .47 .41 .31 - .02 .12 - .09 .02 - .02 .13 .30 .31 .27 - .18 - .12 .29 .11 .06

Factor I1

Factor I11

.03 .04

- .05 - .09

.36

.38 .27 .25 - .06 - .06 .05 - .12 .29 - .32 .08 - .06 .10 - .42 .10 - .41 .15 .20 - .13 .79 .70 .67 .52 .47

- .05

.09 .30 .30 .02 .04

.18 .16 .83 .74 .67 .64 .58 .52 .48 .47 .36 - .04 - .16 .05 .15 .33

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with the exception of purging behavior. The inclusion and exclusion criteria were identical to those in Study 1. Subjects in this cohort had a mean age of 45.1 (SD = 10.6, range 21-65). Mean BMI was 38.9 ( S D = 7.2, range 26.6-55.8). Measures

To assess construct, criterion, and discriminant validity, subjects completed the following measures: (1) The Binge Eating Scale (BES; Gormally et al., 1982), a 16-item self-report scale designed to assess the extent and severity of binge eating among the obese; (2) the TFEQ (Stunkard & Messick, 1985), a 51-item instrument measuring cognitive restraint of eating, hunger, and disinhibition; (3) the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a 21-item self-report scale measuring depression severity; (4) the Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1979), a 10-item self-report scale assessing global self esteem; and (5) the Symptom Checklist (SCL-90-R Derogatis, Lipman, & Covi, 1973) which was developed to assess psychiatric symptomatology in outpatients, and includes a number of specific scales (e.g., hostility, anxiety, somatization) as well as a General Symptom Index. Frequency of binge eating was measured with a 7-day calendar recall method. Subjects were asked to recall binge episodes for each day of the past week. This method has been demonstrated to be reliable (Wilson, 1987). Results The items of the EES were again factor analyzed using procedures identical to those used in the first sample and a similar three-factor structure emerged. The mean EES subscale scores for this second sample were Anger/Frustration (Factor I), 26.85 (SD = 8.71, range = 542,median = 29), Anxiety (Factor 11), 16.49 ( S D = 7.31, range = 3-31, median = 16), and Depression (Factor 111), 12.96 (SD = 3.62, range = 5-20, median = 13). To assess construct validity, all subjects in the second sample filled out a measure assessing the severity of binge eating (BES) and the 7-day recall of binge days. Theoretically, higher levels of emotional eating should correlate with greater severity of binge eating. Significant correlations were found between the EES subscales and both the BES and the 7-day recall of days on which binge eating reportedly occurred (see Table 2). Thus there is good evidence of construct validity. Discriminant validity was assessed through measurement of attitudes toward eating (TFEQ), psychological adjustment (BDI, SCL-90-R), and self-esteem (RSE). In support of the discriminant validity of the EES, none of the measures of psychological adjustment (BDI, SCL-90-R, RSE) were significantly related to the EES. Furthermore, no association was found between the EES subscales and the Cognitive Restraint Factor of the TFEQ. Significant correlations were found between the EES AngerFrustration and Depression subscales and the TFEQ Disinhibition scale. However this finding is expected given that six of the items in the Disinhibition scale have been shown to be related to emotional eating (Ganley, 1988). Criterion-related validity was assessed by examining the relationship between changes in the EES subscales and response to treatment aimed at reducing binge eating. The changes in scores on the EES subscales were compared to changes in binge eating measures pre and posttreatment (see Agras et al., in press, for an outline of treatment). Changes in the subscales all correlate significantly with changes in the BES (Anger/ Frustration Y = .47, Anxiety r = .37, and Depression r = .44). Changes in the Anger/ Frustration subscale (r = .46) and Anxiety subscale (r = .37) also correlate significantly

as

Emotional Eating

Table 2. Correlation coefficients for Emotional Eating Scale subscales with validity measures EES-I (AngeriFrustration) Gormally BES 7-day recall of binge days TFEQ Cognitive Restraint TFEQ Disinhibition SCL-90-R GSI Beck Depression Rosenburg Self-Esteem

.65*** .46*** - .10 .29* .24 .15 .22

EES-I1 (Anxiety) .50**'

.a**

- .09

.05 .18 .01 .15

EES-111 (Depression) .46*** .44** .06 .29* .17 - .01 .15

Note. BES = Binge Eating Scale; TFEQ = Three Factor Eating Questionnaire; SCL-90-R = Symptom Checklist; GSI = General Symptom Index. *p < .05.

**p < .01. ***p < ,001.

with changes in 7-day recall of binge days, however change in the Depression subscale does not (Y = .23). Regarding magnitude of change, the EES AngedFrustration subscale was significantly lower following treatment [t(49) = 5.21, p < .001], but neither the Anxiety nor the Depression subscales changed significantly. Overall, however, the results support the criterion-related validity of the EES. Study 3

The aim of Study 3 was to assess the discriminant efficiency of the EES by administering it to a group of subjects diagnosed with an anxiety disorder. Method Subjects

Subjects were 18 women and 8 men who were patients in two separate fee-for-service groups at the Stanford University Behavioral Medicine Clinic aimed at providing relief from anxiety disorders. All subjects met DSM-111-R criteria for either panic disorder with agoraphobia, social phobia, simple phobia, or agoraphobia without history of panic disorder. Subjects were also screened for the presence of eating disorders (see below). Interestingly, of the 26 subjects 2 males and 6 females had current eating disorders and were excluded leaving a sample of 18. Mean age of the remaining participants was 37.65 (SD = 7.74, range 26-58). Procedure

All participants were asked whether they would be willing to complete a questionnaire regarding their eating habits that was part of an ongoing research project at Stanford University. None of the subjects refused. They were also given a 9-item screen assessing for the presence of an eating disorder. The questions asked included whether the subject considers his or her eating pattern to be abnormal, whether he or she binge eats, whether there is a sense of loss of control during such episodes, how frequently such episodes take place, and whether there is a history of, or current purging. ResuIts

To compare the responses of the anxiety disorder group to binge eaters, scores of the latter group of subjects from Studies 1 and 2 were combined. Means for the three sub-

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scales were significantly higher in the combined sample of binge eaters. For the EES AngedFrustration subscale, the mean for the anxiety disorder group was 5.1 ( S D = 4.3) and for the binge eaters 25.4 ( S D = 8.4) [t(114) = - 10.00, p < .001]. For the EES Anxiety subscale, the mean for the anxiety disorder group was 4.0 ( S D = 4.2) and for the binge eaters 15.9 ( S D = 6.9) [t(114) = -7.02, p < .001]. For the EES Depression subscale, the mean for the anxiety disorder group was 5.2 ( S D = 3.6) and for the binge eaters 12.5 ( S D = 3.8 It(114) = - 7.57 p < .001]. Thus the results provide support for the discriminant efficiency of the EES.

SUMMARY AND DISCUSSION The EES was designed to facilitate investigation of the relationships between specific negative emotional states and overeating. Preliminary results indicate that it is internally consistent, and that it demonstrates adequate temporal stability. Its three separate subscales, Anger/Frustration, Anxiety, and Depression, were confirmed in the factor solution. All of the subscales correlated significantly with 1 week recall of days on which binge eating occurred and with the BES (Gormally et al., 1982). The evidence therefore suggests that higher levels of binge eating are associated with the desire to eat when experiencing negative affect. The EES subscales were unrelated to measures of general psychopathology and selfesteem, including the BDI (Beck et al., 1961), the SCL-90-R (Derogatis et al., 1973), and the RSE (Rosenberg, 1979). While this supports the discriminant validity of the EES, suggesting that the subscale scores are not attributable to correlation with a more general psychopathology factor, the absence of correlation between the EES Depression subscale and the BDI warrants comment. The lack of relationship between these two measures is probably due to the different kinds of questions each asks. The BDI asks about one’s current mood. It is a measure of the intensity of depression (Beck et al., 1961). The EES Depression subscale asks specifically about one’s desire to eat when one feels depressed. The association between the EES AngedFrustration and Depression subscales and the Disinhibition scale of the TFEQ (Stunkard & Messick, 1985) is not surprising given Ganley’s finding (1988) that emotional eating is a component of the Disinhibition factor. More surprising is the lack of association between the EES Anxiety subscale and the TFEQ Disinhibition scale. While this finding is puzzling, it may be partly accounted for by the fact that the Disinhibition scale, as Ganley (1988) noted, comprises two factors, one involving weight fluctuation and the other emotional eating. As Eldredge et al. (in press) reported, in a study of 86 obese binge eaters between baseline and the beginning of a diet, those whose EES scores reflected overeating primarily when depressed or angry gained significantly more weight than those who overate in response to anxiety. The latter group lost a marginal amount of weight. It is possible that overeating in response to anxiety is less unbridled and therefore associated with less weight fluctuation than eating in response to either anger or depression. For the most part, treatment-associated changes in binge eating were associated with changes in the EES subscales. Changes in all three subscales correlated significantly with changes in the BES (Gormally et al., 1982), and changes in 7-day recall of binge eating correlated significantly with changes in the AngedFrustration and Anxiety subscales. However, the correlation between the 7-day recall measure and the Depression subscale failed to reach significance. In addition, though the EES AngedFrustration subscale was significantly lower following treatment, the Anxiety and Depression subscales were not. In considering this pattern of results it is important to note that one third of the subjects

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in the treatment study received cognitive-behavioral therapy (CBT) for weight loss only based on the LEARN Program for Weight Control (Brownell, 1985), two thirds received CBT for binge eating followed by weight loss therapy, and one third received desipramine in addition to CBT for binge eating followed by weight loss treatment (Agras et al., in press). Emotional eating was not the primary target in any of these therapies. In a prior study of the efficacy of desipramine in the treatment of nonpurging binge eaters (McCann & Agras, 1990), the authors noted that the mechanism of action appeared to be appetite suppression which facilitated increased restraint rather than changes in levels of depression or in subjects’ ability to manage depression. And the weight loss treatment, based on the LEARN manual (Brownell, 1985), emphasized alterations in diet, exercise, and eating habits rather than emotional eating. The manual used in the CBT for binge eating conditions was used in a prior study (Telch, Agras, Rossiter, Wilfley, & Kenardy, 1990)and was based largely on CBT for bulimia nervosa. While some attention was paid to tracking mood changes and other precipitants to binge episodes, the major emphasis is on altering patterns of restraint that presumably underlie binge eating disorder, including encouragement to eat three meals daily, and avoiding “forbidden foods” (see Telch et al., 1990 for a description of the manual). It is therefore not surprising that these therapies failed to demonstrate a broader impact upon the urge to eat during negative emotional states. On the other hand, the significant change in the AngedFrustration subscale might have been due to the fact that CBT intervention to normalize one’s eating pattern and avoid forbidden foods probably reduces the sense of failure and inadequacy that seems to characterize binge eaters’ relationships with food. Among the items on that subscale that might have been affected by such intervention include ”Guilty,” ”Discouraged,” ”Inadequate,” “Helpless,” “Frustrated,” and ”Rebellious.“ Perhaps the most interesting finding is the strong relationship between all EES subscales and the 7-day recall of days on which binge eating occurred, combined with an absence of correlation between the EES and the Cognitive Restraint subscale of the TFEQ. This provides some indirect support for a suggestion in our earlier report (Arnow et al., 1992)that negative mood may precipitate binge eating in obese patients regardless of levels of restraint. This is relevant not only to our attempts to understand binge eating disorder, but also to treatment since current cognitive-behavioral approaches assume the presence of restraint in these patients, and spend considerable therapeutic effort attempting to attenuate it. Recent evidence from other studies as well suggests that restraint may not be as critical a variable among obese binge eaters as was initially reported. For instance, Wilson, Nonas, and Rosenblum (1993) reported that only 8.7% of a cohort of binge eaters seeking obesity treatment reported having been on a “strict diet” prior to beginning binge eating. And while an earlier investigation (Marcus et al., 1985) found that compared with obese nonbingers, self-reports of obese binge eaters indicated significantly higher levels of restraint, a more recent investigation using the Eating Disorders Examination (Cooper & Fairburn, 1987), a structured clinical interview, found that the Restraint subscale scores of obese bingers were significantly lower than those of normal weight bulimia nervosa subjects (Marcus, Smith, Santelli, & Kaye, 1992). The EES was developed in a clinical population and its applicability to nonclinical populations is unknown. In addition, as it was intended to permit more differentiated study of the phenomenon of emotional eating, the meaning of a total score is unclear and may obscure the specific relationships the measure was designed to illuminate. Thus results should be reported by specific subscale. This research was supported in part by grant MH38637 from the NIH.

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APPENDIX 1 Emotional Eating Scale

We all respond to different emotions in different ways. Some types of feelings lead people to experience an urge to eat. Please indicate the extent to which the following feelings lead you to feel an urge to eat by checking the appropriate box.

Upset

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