"Maze Out": a study protocol for a randomised controlled trial using a mix methods approach exploring the potential and examining the effectiveness of a serious game in the treatment of eating disorders.

BACKGROUND: Eating Disorders (ED) are severe and costly mental health disorders. The effects of existing treatment approaches are limited and there is a need to develop novel interventions, including digital strategies that can increase engagement and effectiveness. Maze Out is a new serious game coproduced by patients and ED therapists, which allows patients to "play" with the reality of an ED and reflect on associated challenges. OBJECTIVES: The present study has two main objectives: (1) to evaluate the effectiveness of adding Maze Out to treatment as usual (TAU) in a randomised controlled trial (RCT); and (2) to examine in depth the potential of Maze Out by examining how it is perceived and used in the context of an RCT. METHODS: Participants will be recruited from mental health care services, endocrinology departments or Community Centres offering treatment for ED. Patients suffering from ED (N = 94) will be randomised to either TAU or TAU plus Maze Out. Primary outcome will be measured in terms of changes in self-efficacy, measured by a 5-item self-efficacy questionnaire (5-item SE_ED). Secondary outcome measures will include feelings of ineffectiveness and self-image, as measured by Eating Disorder Inventory, version 3 (EDI-3), Brief INSPIRE-O and Structural Analysis of Social Behaviour Intrex Questionnaire (SAS-B). Data will be collected at baseline (enrolment in the study), and subsequently 8 and 15 weeks after inclusion. Experiences of playing Maze Out will be examined in a sub-sample of participants, utilising both quantitative user analytics and qualitative interview data of patients, interview data of significant others, and healthcare professionals to explore the possible impact of Maze Out on disorder insight, communication patterns between patients and therapists and understanding of their disorder. DISCUSSION: To our knowledge Maze Out is the first serious game coproduced by patients and therapists. It is a novel and theoretically grounded intervention that may significantly contribute to the healing process of ED. If found effective, the potential for wide-spread impact and scalability is considerable. Trial registration ClinicalTrials.gov NCT05621018.

Emotion dysregulation and eating disorder outcome: Prediction, change and contribution of self-image.

OBJECTIVES: Eating disorders (EDs) are severe disorders with unsatisfactory outcome. Emotion dysregulation and self-image are suggested maintenance factors; this study examined emotion dysregulation as potential predictor and/or mechanism of change in relation to ED outcome, and associations between change in emotion dysregulation and self-image in relation to outcome. DESIGN: Registry data from initial and 1-year follow-up assessments for 307 patients with a wide range of EDs in specialized ED treatment were used. METHODS: Initial and change (∆) in emotion dysregulation were examined as predictors of 1-year outcome. Direct and indirect associations between ∆emotion dysregulation and ∆self-image as either independent variable or mediator in relation to ∆ED psychopathology as dependent were also examined. RESULTS: Higher initial emotion dysregulation was weakly associated with higher follow-up ED psychopathology, but not remission, while relative increase in emotion dysregulation was associated with both higher follow-up psychopathology and increased risk of still having a diagnosis. Change in emotion dysregulation primarily had an indirect effect (through change in self-image), while change in self-image had a direct effect, on change in ED psychopathology improvement (such that improvement in one was associated with improvement in the other). CONCLUSIONS: Results identify emotion dysregulation as a potential mechanism of change in relation to ED outcome. However, this association was mainly mediated by change in self-image. Results indicate that, in order to improve emotion regulation as a means to reduce ED psychopathology, improving self-image is essential.

Binge Eating and Addictive-Like Behaviours in Males and Females.

INTRODUCTION: Binge eating is a common behaviour that is strongly linked to both obesity and eating disorder. There is evidence that binge eating commonly co-occurs with other problematic and addictive-like behaviours; however, this has not been explored systematically. The present study aimed to examine the relationship between binge eating, body weight, disordered eating behaviours and associated addictive-like behaviours, with particular attention paid to gender differences. METHOD: A community sample (N = 500; 75% female, Mage = 32.5 years) reported disordered eating behaviours (i.e. binge eating, purging, restriction of eating, compulsive exercise), body mass index (BMI), food addiction, starvation addiction, exercise dependence, tobacco use and alcohol consumption. RESULTS: 42% of females and 21% of males reported binge eating during the past four weeks. Binge eating was significantly associated with all investigated behaviours in females, and with purging, compulsive exercise and overweight/obesity in males. Controlling for BMI, self-starvation predicted binge eating in males (OR = 1.07), while food addiction (OR = 1.73) and alcohol dependence (OR = 1.11) predicted binge eating in females. CONCLUSIONS: The multiple associations between binge eating and addictive-like behaviors supports broad screening and generalized prevention efforts. Prevention efforts should reflect gender differences.

Longitudinal experiences and impact of the COVID-19 pandemic among people with past or current eating disorders in Sweden.

The study aimed to document the impact of the COVID-19 pandemic on the health and well-being of individuals with past and current eating disorders (ED) in Sweden. We re-contacted participants with a known lifetime history of ED from two previous Swedish studies. Participants completed an online survey about health and functioning at baseline early in the pandemic (Wave 1 ca May/June 2020; N= 982) and six months later (Wave 2 Dec/Jan 2020/21; N= 646). Three important patterns emerged: 1) higher current ED symptoms were associated with greater anxiety, worry, and pandemic-related ED symptom increase; 2) patterns were fairly stable across time, although a concerning percentage (23%) who were symptom-free at Wave 1 reported the re-emergence of symptoms at Wave 2; and 3) only a minority of participants (<50%) with a current ED were in treatment, and of those in treatment, many reported fewer treatment sessions and decreased quality of care. The COVID-19 pandemic appears to pose serious health challenges for individuals with an ED, whether currently symptomatic or in remission. We encourage health service providers and patient advocates to be alert to the needs of individuals with ED and to take active measures to ensure access to appropriate evidence-based care both during and following the pandemic.

Impulsivity and compulsivity as parallel mediators of emotion dysregulation in eating-related addictive-like behaviors, alcohol use, and compulsive exercise.

INTRODUCTION: Transdiagnostically relevant psychological traits associated with psychiatric disorders are increasingly being researched, notably in substance use and addictive behaviors. We investigated whether emotion dysregulation mediated by impulsivity and/or compulsivity could explain variance in binge eating, food addiction, self-starvation, and compulsive exercise, as well as alcohol use (addictive-like behaviors relevant to the obesity and eating disorder fields). METHOD: A general population sample of adults (N = 500, mean age = 32.5 years), females (n = 376) and males (n = 124), completed the Difficulties in Emotion Regulation Scale-16, the Trait Rash Impulsivity Scale, the Obsessive-Compulsive Inventory-Revised, the Eating Disorders Examination Questionnaire, the Self-Starvation Scale, the Exercise Dependence Scale, the Yale Food Addiction Scale, and the Alcohol Use Disorders Identification Test online. Besides gender comparisons and intercorrelations between measures, we used predefined multiple mediation models with emotion dysregulation as independent variable, impulsivity and compulsivity as parallel mediators, to investigate whether these factors contributed explanatory power to each addictive-like behavior as outcome, also using age and body mass index as covariates. RESULTS: Females scored higher than males on emotion dysregulation and the eating-related addictive-like behaviors food addiction, self-starvation, and binge eating. Intercorrelations between measures showed that emotion dysregulation and compulsivity were associated with all outcome variables, impulsivity with all except compulsive exercise, and the eating-related behaviors intercorrelated strongly. Mediation models showed full or partial mediation of emotion dysregulation for all behaviors, especially via compulsivity, suggesting a behavior-specific pattern. Mediation models were not affected by age or gender. DISCUSSION: Addictive-like behaviors seemed to be maintained by trait levels of emotion dysregulation, albeit channeled via trait levels of compulsivity and/or impulsivity. The role of emotion dysregulation may help us to understand why addictive-like behaviors can be difficult to change in both clinical and nonclinical groups, and may be informative for treatment-planning in patients where these behaviors are present. Our findings support adopting a more dimensional approach to psychiatric classification by focusing psychological facets such as those studied.

Initial self-blame predicts eating disorder remission after 9 years.

BACKGROUND: Research into predictors of outcome in eating disorders (ED) has shown conflicting results, with few studies of long-term predictors and the possible importance of psychological variables that may act as risk- and maintenance factors. AIM: To identify baseline predictors of ED remission nine years after initial clinical assessment using self-report measures of ED psychopathology, psychiatric symptoms, and self-image in a sample of adult ED patients (N = 104) treated at specialist units in Stockholm, Sweden. Sixty patients participated in the follow-up, of whom 41 patients (68%) had achieved remission. RESULTS: Results suggested that the only significant predictor of diagnostic remission after nine years was initial levels of self-blame. CONCLUSION: In order to ensure long-term recovery in ED it may be important for clinicians to widen their therapeutic repertoire and utilise techniques that reduce self-blame and increase self-compassion. It is difficult to predict how an eating disorder will develop, and research has found varying factors that affect the outcome of the condition. Recovery rates vary from nearly nil to over 90%. This variation could be explained by different research factors, but are more likely due to varying definitions of 'recovery', with less stringent definitions yielding high recovery rates and more stringent definitions yielding lower rates. The present study investigated whether the severity of eating disorder symptoms and other psychiatric symptoms could predict recovery nine years from first admission to specialised eating disorder care. Sixty patients at three eating disorder treatment units participated, and their scores on self-report measures of symptoms were used as predictor variables. Forty-one participants had no eating disorder diagnosis at nine-year follow-up. Most participants with binge-eating disorder had recovered, while the poorest outcome was found for anorexia nervosa with slightly over half of patients recovered after nine years. The only predictor for the nine-year outcome was a higher initial rating of self-blame, measured with the Structural Analysis of the Social Behavior. It was concluded that it may be important for clinicians to detect and address self-blame early in the treatment of eating disorders in order to enhance the possibility of recovery. Treatment should focus on reducing self-blame and increasing self-acceptance.

Self-directed behaviors differentially explain associations between emotion dysregulation and eating disorder psychopathology in patients with or without objective binge-eating.

BACKGROUND: Emotion dysregulation and negative self-directed behaviors are key characteristics of eating disorders (EDs), but their interaction in relation to ED psychopathology is insufficiently explored, and empirically robust and clinically relevant models are needed. METHODS: This study examined whether the association between emotion dysregulation and ED psychopathology was mediated by different negative self-directed behaviors in 999 ED patients divided into two sub-samples based on absence or presence of objective binge-eating episodes (OBE). Several simple and extended mediation models were examined using the Difficulties in Emotion Regulation Scale (DERS) as independent variable, the Structural Analysis of Social Behavior (SASB) as mediator, and the Eating Disorder Examination Questionnaire (EDE-Q) as dependent variable. RESULTS: An associational pathway was found where higher emotion dysregulation was associated with more negative self-directed behaviors, which in turn was associated with higher ED psychopathology. Self-directed behaviors of importance differed between patient groups. In participants without OBE, lower self-love and higher self-attack were influential, whereas in participants with OBE, lower self-affirmation and higher self-blame were influential. CONCLUSIONS: Self-directed behaviors may help to explain the association between emotion dysregulation and ED psychopathology. Our findings have both theoretical and clinical implications that are pathology-specific. Addressing specific self-directed behaviors could be an important way of helping patients deal with their emotions in relation to ED psychopathology.

Personality as predictor of outcome in internet-based treatment of bulimic eating disorders.

Internet-based cognitive behavioral therapy (ICBT) for bulimic eating disorders has demonstrated clinical utility and cost efficiency, but is associated with low patient preference, low credibility, sizeable dropout and only moderate symptom reduction. To improve outcome it is imperative to learn more about who might benefit from internet-based interventions. To do this, the current study investigated the Five Factor Model of personality as predictor of outcome in patients with full or sub-threshold bulimia nervosa (n = 109). Patients in a randomized controlled trial of ICBT were assessed prior to and at the end of treatment. Patients showed significant symptom reduction over time (Cohen's d = 1.0, p < .001). Remission as well as overall symptom reduction was positively predicted by Openness to Experience and Conscientiousness. Binge eating cessation specifically, was positively predicted by Extraversion. The study supports the use of personality assessment for patient selection and outcome optimization in internet-based treatment of bulimic eating disorders.

The unsafe haven: Eating disorders as attachment relationships.

OBJECTIVES: Some patients with eating disorders (EDs) seem to experience their illness as an entity, a symbolic other to whom they relate, and which may influence both symptom levels and self-image. Extending previous research, this study investigated whether the patient-ED relationship has attachment qualities. DESIGN: Structural Analysis of Social Behaviour was used to operationalize the patient-ED relationship, and the Attachment Style Questionnaire was used to measure attachment. METHOD: We examined ED patients' (N = 148) relationship with their ED, attachment behaviour, symptoms, and self-image. Attachment dimensions of Confidence, Anxious/ambivalence, and Avoidance were found to be significantly correlated with aspects of the patient-ED relationship. Introjection (i.e., whether ED actions were incorporated into patients' self-image) was investigated by examining the match between self-image profiles and the actions of patients' EDs. A double mediation model was tested in which ED control/emancipation and patients' Self-blame mediated the effect of attachment security on ED symptoms. RESULTS: Attachment insecurity was associated with greater ED control and patient submission. In 28.5% of patients, there was a high degree of correlation between self-image and ED action profile. Data supported the mediation model. CONCLUSIONS: Attachment processes appear to be associated with the manner in which ED patients relate to their disorder, at least in some cases. Attempts to maintain psychological proximity to the ED as an introjected attachment figure may help to explain treatment resistance and ambivalence about change. This perspective may be useful in treatment. PRACTITIONER POINTS: Attachment behaviours are associated with the patient-ED relationship, in which attachment insecurity is correlated with greater eating disorder control and patient submission. Some patients seem to incorporate the actions of the ED in their self-image, suggesting the presence of introjection. The patient-ED relationship may help explain patients' anxiety and ambivalence about change, seen from an attachment perspective. In treatment, it may be important to explore alternative safe havens and secure bases to the ED, such as interpersonal relationships and activities.

Emotion dysregulation and eating disorders-Associations with diagnostic presentation and key symptoms.

OBJECTIVE: Emotion dysregulation seems involved in the development, maintenance, and outcome of eating disorders (EDs). The present study aimed to differentiate patients with EDs from a comparison group on emotion dysregulation, and to examine emotion dysregulation in relation to ED diagnostic presentation and ED symptoms. METHOD: Participants, patients with EDs (N = 999) and a student comparison group (N = 252), completed the Difficulties in Emotion Regulation Scale and the Eating Disorder Examination Questionnaire. Patients were compared to the comparison group and compared by diagnosis regarding emotion dysregulation, and unique associations between emotion dysregulation aspects and ED symptoms were examined. RESULTS: Patients reported greater general emotion dysregulation than the comparison group, especially poorer emotional awareness and clarity. There were very few diagnostic differences. In both patients and the comparison group, limited access to emotion regulation strategies was associated with cognitive ED symptoms, and presence of binge eating in the comparison group. In patients, poor emotional awareness and emotional non-acceptance were additionally associated with cognitive symptoms, and difficulties in impulse control and emotional non-acceptance were associated with binge eating. DISCUSSION: Emotion dysregulation is an important transdiagnostic characteristic of ED. Results suggest interventions that enhance emotional awareness and acceptance, as well as emotion regulation skills training, in both ED treatment and prevention.

Perfectionism in Eating Disorders: Are Long-Term Outcomes Influenced by Extent and Changeability in Initial Perfectionism?

PURPOSE: Perfectionism has been found to predict outcomes in the treatment of eating disorders (ED). In the present study, we took advantage of longitudinal data to: a) investigate whether there are different patterns of perfectionism during the first six months after admission in a clinical sample of patients with ED, and b) describe how these patterns are related to long-term outcome. METHODS: A sample of patients (N=294) from the Coordinated Evaluation and Research at Specialized Units for Eating Disorders database was divided into clusters according to perfectionism patterns measured with the EDI-2 perfectionism scale at baseline, and six months in treatment. Cluster analysis was performed on the extent and perseverance/changeability of self-oriented and socially described perfectionism. Outcome was measured with the EDI-2 and the SCL-63. Frequencies of eating disorder diagnoses were investigated. RESULTS: Five clusters were identified. Low perfectionism was associated with lower levels of ED and psychiatric symptomatology at baseline. There were no significant differences between clusters on outcome variables at 36-month follow-up. CONCLUSIONS: Results indicated better psychiatric and psychological health three years after the initial measure. Patterns of relations between the extent and possible changes of perfectionism, measured with the EDI-P at baseline and after six months, did not appear to be associated with long-term outcomes on psychiatric health ratings.

Insidious: The relationship patients have with their eating disorders and its impact on symptoms, duration of illness, and self-image.

OBJECTIVES: In published clinical and autobiographical accounts of eating disorders, patients often describe their disorder in personified ways, that is, relating to the disorder as if it were an entity, and treatment often involves techniques of externalization. By encouraging patients to think about their eating disorder as a relationship, this study aimed to examine how young female patients experience their eating disorder as acting towards them, how they react in response, and whether these interactions are associated with symptoms, illness duration, and self-image. DESIGN: Structural Analysis of Social Behavior (SASB) was used to operationalize how patients experience the actions of their eating disorder and their own reactions to the disorder. METHOD: The relationship between patients (N = 150) and their eating disorders was examined with respect to symptoms, duration of illness, and self-image. Patients were also compared on their tendency to react with affiliation in relation to their disorder. RESULTS: Patients' responses on the SASB indicated that they tended to conceptualize their eating disorders as blaming and controlling, and they themselves as sulking and submitting in response. Greater experience of the eating disorder as being controlling was associated with higher levels of symptomatology. Patients reacting with more negative affiliation towards their disorder were less symptomatic. CONCLUSIONS: When encouraging patients to think about their eating disorder as a relationship, comprehensible relationship patterns between patients and their eating disorders emerged. The idea that this alleged relationship may resemble a real-life relationship could have theoretical implications, and its exploration may be of interest in treatment. PRACTITIONER POINTS: Patients were able to conceptualize their eating disorder as a significant other to whom they relate when encouraged to do so. Patients tended to experience their disorder as controlling and domineering. Exploring the hypothetical patient-eating disorder relationship may prove helpful in understanding dysfunctional relational patterns. Helping patients to rebel against their eating disorder could potentially aid in symptom reduction.

Factor analysis of the adolescent version of the Eating Disorders Examination Questionnaire (EDE-Q): results from Swedish general population and clinical samples.

BACKGROUND: Although the Eating Disorder Examination Questionnaire (EDE-Q) is perhaps the single most widely used self-report measure of eating disorder (ED) symptoms, important questions remain about its validity and applicability in relation to particular groups of individuals, especially adolescents of both genders. METHODS: The present study investigated the factor structure of the adolescent version of the Eating Disorder Examination Questionnaire (EDE-Q) in samples of Swedish girls and boys from the general population and girls with a diagnosed eating disorder. Girls (N = 239) and boys (N = 248) aged between 13 and 15 years who were attending school, and girls (N = 570) aged between 12 and 14 years who were in treatment for an eating disorder at a specialist eating disorder clinic were assessed on the adolescent version of the EDE-Q. RESULTS: The adolescent version of the EDE-Q demonstrated satisfactory levels of internal consistency. However, confirmatory factor analysis (CFA) failed to support the four-factor model of the EDE-Q. Parallel analysis (PA) and subsequent exploratory factor analysis (EFA) suggested that the adolescent version of the EDE-Q comprises one underlying factor in young adolescent girls (both clinical and general population), centred on Dissatisfaction with Shape and Weight. In boys three factors were found: Weight-related Concerns, Body Discomfort and Restraint. CONCLUSIONS: The EDE-Q appears to measure different underlying aspects of eating disorder psychopathology in young teenagers compared to adults. The dimensions underlying disordered eating in young girls may become increasingly differentiated with time. There appear to be important gender-based differences in the dimensions underlying the EDE-Q in young teenagers. Therapists should be alert to beliefs that girls have about the importance of shape and weight, while in boys it may be more important to be attentive to how they feel about their bodies in relation to weight.

Classifying empirically valid and clinically meaningful change in eating disorders using the Eating Disorders Inventory, version 2 (EDI-2).

The study examined the ability of the EDI-2 to classify empirically valid and clinically meaningful change using clinical significance and the Reliable Change Index (CS/RCI), and compared CS/RCI to classification based on diagnostic change. Eating disorder (ED) patients (N=363) were assessed at intake and after 36months on measures of ED and psychiatric symptoms, self-image, interpersonal relationships, treatment satisfaction and general outcome. Patients were categorized using a four-way classification scheme as "Deteriorated", "Unchanged", "Improved" or "No ED"; and using a two-way classification scheme as either in remission or not in remission. Compared to similar two- and four-way classification based on diagnostic change, CS/RCI using the EDI-2 total score demonstrated greatest overall utility in explaining outcome variance. The EDI-2 can generate empirically valid and clinically meaningful classification of change. Systematic application of CS/RCI using the EDI-2 benefits both clinicians and researchers by providing a simple, clinically relevant, scientifically robust, and cost-effective means of classifying outcome. It may be especially relevant in alerting clinicians to problem cases in need of additional or alternative treatment strategies.

Take charge: Personality as predictor of recovery from eating disorder.

Many treatments for eating disorders (ED) have demonstrated success. However, not all patients respond the same to interventions nor achieve full recovery, and obvious candidates like ED diagnosis and symptoms have generally failed to explain this variability. The current study investigated the predictive utility of personality for outcome in ED treatment. One hundred and thirty adult patients with bulimia nervosa or eating disorder not otherwise specified enrolled in an intensive multimodal treatment for 16 weeks. Personality was assessed with the NEO Personality Inventory Revised (NEO PI-R). Outcome was defined as recovered versus still ill and also as symptom score at termination with the Eating Disorder Inventory-2 (EDI-2). Personality significantly predicted both recovery (70% of patients) and symptom improvement. Patients who recovered reported significantly higher levels of Extraversion at baseline than the still ill, and Assertiveness emerged as the personality trait best predicting variance in outcome. This study indicates that personality might hold promise as predictor of recovery after treatment for ED. Future research might investigate if adding interventions to address personality features improves outcome for ED patients.

Eating disorder symptoms pre- and postpartum.

The study aimed to investigate symptoms of disordered eating pre- and postpartum using a standardised and widely used measure of eating disorder (ED) psychopathology. A consecutive series of women attending either prenatal (N = 426) or postnatal (N = 345) clinics in metropolitan Stockholm were assessed using the Eating Disorder Examination Questionnaire (EDE-Q). Assessments were conducted at either the first visit to prenatal clinics (10-12 weeks of pregnancy) or 6 to 8 months postpartum. An optimised shortened version of the EDE-Q was best suited for studying eating disorders pre- and postpartum. Using the optimised version of the instrument with 14 items and a cut-off score of ≥2.8, it was estimated that 5.3 % of prepartum and 12.8 % of postpartum mothers were suffering from clinical eating disorders. Seriously disordered eating behaviour during, and especially after, pregnancy may be more common than previously thought. It is imperative that health services focus increased attention on these problems by raising awareness, developing and extending specialist services, as well as through implementing educational programmes and training directed toward frontline healthcare services.

Who do you think you are? - Personality in eating disordered patients.

BACKGROUND: The Five-Factor Model of personality is strongly linked to common mental disorders. Yet the relationship between the lower order personality traits (facets) of the model and eating disorder (ED) features remains unclear. The aim of the study was to explore how patients with non-anorexic ED differ from controls in personality and to examine the ability of personality facets to explain psychopathology. METHODS: Female patients with non-anorexic ED (N = 208) were assessed on general psychopathology, ED symptoms and personality as measured by the NEO PI-R; and were compared on personality to age-matched female controls (N = 94). RESULTS: Compared to controls, patients were characterised by experiencing pervasive negative affectivity and vulnerability, with little in the way of positive emotions such as joy, warmth and love. Patients were also significantly less warm and sociable, and exhibited less trust, competence, and self-discipline. Finally, they were less open to feelings, ideas and new experiences, yet more open in their values. Among patients, personality facets explained up to 25% of the variance in ED and general psychopathology. CONCLUSIONS: ED patients have distinct patterns of personality. Identifying and focusing on personality traits may aid in understanding ED, help therapists enhance the treatment alliance, address underlying problems, and improve outcome.

Drop-in access to specialist services for eating disorders: a qualitative study of patient experiences.

Lack of patient motivation and dropout are common problems in the treatment of eating disorders. The present study explored patient experiences with open access to specialist eating disorder services through a drop-in program aiming to enable early identification of eating disorders, address motivational problems, and strengthen the therapeutic alliance. Semi-structured qualitative interviews were used to explore the experiences of 11 individuals attending the program. Results suggest that drop-in access may strengthen the therapeutic alliance, motivate engagement in treatment, and reduce dropout. Strengths and weaknesses of the program are discussed and the need for more systematic research is elaborated.

Binge eating in interview versus self-report: different diagnoses show different divergences.

OBJECTIVE: Binge eating (BE) is diagnostically important for eating disorders (EDs) but difficult to measure validly and reliably. The study compared interview and questionnaire formats regarding the proportion of patients in each diagnostic group who reported BE. METHOD: Data came from the clinical Stepwise ED database (N=3508 adults and 1354 children/adolescents), representing the full range of ED diagnoses. Methods used were the Structured ED Interview and the ED Examination Questionnaire. RESULTS: Opposite discrepancies were observed between methods depending on ED diagnosis, such that a higher number of restrictive patients reported BE on the questionnaire than the interview, whereas the opposite was true for bulimic patients. DISCUSSION: The findings have important clinical and theoretical implications and suggest that BE assessment is more complex than previously believed.