Introduction
A traumatic experience can cause posttraumatic stress disorder (PTSD), a condition characterized by aspectrum of psychopathological symptoms such as intrusive thoughts, strategies to avoid memories associated with the original trauma, hyperarousal with the sense of current threat, and negative alterations in cognitions and mood 1. The International Classification of Diseases, 11th Revision (ICD-11) proposes the term “complex post-traumatic stress disorder” (cPTSD) as a clinical disorder encompassing the primary symptoms of PTSD. However, it is conceptually distinguished from PTSD based on symptoms that reflect “disorders of self-organisation” (DSO), a cluster of symptoms which is characterized by affective dysregulation (e.g. heightened emotional reactivity, anger outbursts, feeling emotionally numb or dissociated), a negative self-concept (e.g. feeling diminished, defeated or worthless; pervasive feelings of shame, guilt), and enduring disturbances in relationships (e.g., feeling distant from others, having difficulty maintaining intimate relationships 2. Data collected by Brady et al. suggest that the vast majority of individuals with PTSD meet the criteria for at least one other psychiatric disorder, and approximately 50 per cent have three or more psychiatric diagnoses 3. This can be related to the negative consequences on emotion regulation associated with functional impairment beyond PTSD symptom severity 4. PTSD symptoms’ severity has been robustly associated with the lack of emotional awareness, lack of emotional clarity, difficulties with engaging in goal-directed behaviors, impulse control difficulties, nonacceptance of emotions, and dysfunctional beliefs about emotion regulation 5.
A possible psychopathological manifestation of trauma may be related to eating behaviors. Binge eating disorder (BED) is a psychiatric disorder characterized by frequent episodes of binge eating, accompanied by a sense of loss of control and psychological distress, in the absence of compensatory weight-control behaviors such as purging or fasting 1. BED is the most common eating disorder, with a lifetime prevalence of approximately 2% in developed countries 6. Harrington et al. found that trauma exposure significantly predicted women’s binge eating severity 7.
In light of comorbidity, researchers need to explore the factors that may contribute to the maintenance of these two disorders. Rabito-Alcón et al. showed that depressive symptomatology, anxiety, and dissociation significantly mediate the relationship between childhood trauma and eating disorders in adulthood 8. However, no one focused on the possible contribution that the emotional states common to the two conditions could make.
Among individuals with BED, both internal shame (feelings of being lesser than others) and external shame (experience of one’s flaws and deficits being exposed to others) are associated with theseverity of binge eating symptoms 9. Shame is a highly complex, socially important emotion that involves the negative evaluation of the self 10, it represents an emotion often experienced by traumatised individuals. Posttraumatic shame can be construed as acute or prolonged feelings of distress associated with self-attributions of having committed dishonourable acts in the context of the traumatic situation 11. The more global and stable the shame-based attributions following trauma are, the higher the likelihood of posttraumatic symptoms will be 12.
Also guilt is also an emotion often experienced by trauma victims and characterising individuals with Binge Eating behaviour; Raffone et al. showed that guilt represents a central driver for compensatory behaviors in the maladaptive eating behavior cycles 13. Guilt is an unpleasant feeling with an accompanying belief that one should have felt, thought, or acted differently 14. Posttraumatic guilt can be defined as the fact of experiencing acute or prolonged states of guilt in the context of a traumatic situation. It depends on the types of failed enactments in the traumatic situation that generate negative consequences for self and others 11.
Boredom can be considered both an emotional and motivational state. It can be triggered by external factors, such as lack of choice, monotony, and inappropriate levels of challenge 15. Ahlich & Rancourt showed that boredom proneness is a significant predictor of emotional eating 16. It has also been linked to various psychological problems duringthe COVID-19 pandemic, such as increased alcohol and substance use, problematic social media and Internet use, perceived stress, and psychological distress, including symptoms of depression, anxiety, and insomnia 17.
Aims and hypotheses
Based on these considerations, we hypothesized that the severity of trauma and binge eating behaviour might be related and that boredom, shame, and guilt might all play a significant role in predicting binge eating behaviour and in mediating the relationship between posttraumatic and binge eating behaviour. Our goal was to study the relationship between posttraumatic symptomatology and binge eating behavior by focusing on the role that negative emotions triggered and perpetuated by trauma might play in this relationship. Moreover, we wanted to verify the role of shame, guilt, and boredom. Therefore, we aim to investigate the relationships among posttraumatic symptoms, disturbances of self-organization symptoms, binge eating behavior, shame, guilt, and boredom in a non-clinical population. Our goal was to study the relationship between posttraumatic symptomatology and binge eating behavior by focusing on the role that negative emotions triggered and perpetuated by trauma might play in this relationship
Materials and methods
Recruitment
Through Google Forms, publicized and forwarded on major social media networks, a snowball convenience sample of 1025 people was recruited (731 females, 294 males) between 18 and 60 years (mean age 29.62 years). Participants have compiled demographic and self-report questionnaires to assess trauma, binge eating, boredom, shame, and guilt. All participants were informed about the research and did not receive any financial remuneration for participating in this study. The entire protocol was anonymous and the ethical committee of the Department of Dynamic and Clinical Psychology, and Health Studies of the “Sapienza” University of Rome approved this study. All participants who had not consented or responded to all protocol sections were excluded from the research. No specific exclusion criteria were applied.
Measures
Sociodemographic characteristics
We collected some basic socio-demographic information about gender, age, education, nationality, relational status, andsexual orientation, as well as anthropometric parameters to assess body mass index (BMI).
Posttraumatic symptoms
Posttraumatic symptoms were evaluated through theInternational Trauma Questionnaire (ITQ), a brief self-report scale that focuses on posttraumatic stress disorder and complex posttraumatic stress disorder. The ITQ was developed to be consistent with the organizing principles of the ICD-11, as set forth by the World Health Organization, which are to maximize clinical utility and ensure international applicability through a focus on the core symptoms of a given disorder. The ITQ first asks to identify the most distressing traumatic event and how long ago this event occurred. Participants are then instructed to answer all questions about that event. The ITQ includes six items to measure each of the PTSD symptoms across the clusters of Re-experiencing in the Here and Now, Avoidance of internal and external reminders, and Hyperarousal. Participants indicated how much these symptoms have interfered with their ability to function in life in the past month across three items. The ITQ also includes six items measuring each ‘Disturbance in Self-Organization’ (DSO) symptom from the three clusters of ‘Affective Dysregulation’, ‘Negative SelfConcept’, and ‘Disturbed Relationships’. The items use a 5-point Likert scale. Both the subscales, PTSD and DSO, of the Italian version of ITQ, have good reliability with an α=0.88 18,19.
Binge Eating Disorder
The Binge Eating Scale (BES) evaluates Binge Eating behavior. The BES is a 16-item scale self-report measure developed to assess the presence of binge eating behavior (e.g. eating quickly and overeating) and the feelings/cognitions associated with binge eating (e.g. feeling guilty after binge eating) along a 4-point Likert scale. The BES is usually employed as a unidimensional measure of binge eating severity. Marcus has identified three different levels of severity: individuals scoring 17 or less were considered not reporting significant binge eating, those scoring between 18 and 26 were considered moderate binge eaters, and those scoring 27 and above were considered severe binge eaters. These categories had a 98% concordance rate with a diagnosis using a semi-structured interview. The reliability of the Italian version is α=0.89 20,21.
Shame and guilt
Shame and Guilt were assessed with theState Shame and Guilt Scale (SSGS-8), a psychometric test evaluating 8 items along a 5-point Likert scale. The sum of 4 specific items can be used to detect shame and guilt, respectively, as two different domains. In the Italian version, Shame has an α=0.82 while Guilt has an α=0.87 22,23.
Boredom
Boredom was evaluated using the short form of the Multidimensional State Boredom Scale (MSBS-SF). The scale consists of 8 items each rated on a 7-point Likert scale that cumulatively assesses the individual’s experience of boredom. Cronbach’s alpha for the Italian version is 0.95 24,25.
Statistical Analysis
Continuous variables were statistically represented as means and standard deviations (SD). Dichotomic variables were represented statistically as absolute and percentage frequencies. A bivariate Pearson correlation matrix was performed to test the association level among the different variables based on psychometric tests with the related scales and subscales. A multiple linear regression using stepwise methodology was conducted to quantify the relationship between binge eating disorder, which was the outcome variable in our analysis, and PTSD, disturbances in self-organization, shame, guilt, and boredom, which were the explanatory variables. A mediation analysis was conducted using disturbances in self-organization as a predictor variable, binge eating disorder as outcome variable, and significant explanatory variables derived from multiple linear regression as mediating variables. The effects were considered significant when the resulting confidence interval did not contain 0. Each alpha error lower than 5% indicated statistical significance. Data analysis was performed using the program JASP 0.16.3.
Results
Table I shows the sociodemographic characteristics of the recruited sample. The mean scores and standard deviations of the psychometric measures are shown in Table II. The sociodemographic aspects revealed that the sample is mainly composed of women (71.3%) and participants in a relationship (65.8%). The sample consisted of individuals resident in Italy (33.1% living in Rome), almost exclusively with Italian nationality (97.6%).
Through a pairwise correlation matrix, we found that the considered psychometric variables were all positively correlated. The Pearson correlation coefficient among PTSD, DSO, BES, MSBS, Shame and Guilt were all statistically significant (Tab. III).
Multiple linear regression (Tab. IV) in which BES was the outcome variable and DSO, PTSD, Shame, Guilt and MSBS revealed that the significant model characterized by higher adjusted R2 (R2=0.195; p<0.001) was the one with DSO, Shame, and MSBS. Guilt and PTSD were not significant predictors and were therefore excluded from the model conducted with stepwise methodology.
Mediation analysis (Tab. V) revealed a significant direct effect of DSO on BES (Estimate std=0.047; p<0.001); a significant indirect effect of DSO on BES (Estimate std=0.027; p<0.001), in light of the significant mediation of Shame (Estimate std=0.012; p=0.016) and MSBS (Estimate std=0.015; p<0.001); a significant total effect of DSO on BES (Estimate std=0.074; p<0.001). The path plot of the mediation analysis is shown in Figure 1.
Discussion
The association between posttraumatic symptomatology and binge eating symptoms 26,27, is confirmed in this study. The way traumatic events negatively affect eating behavior, however, does not seem primarily to be associated with classic PTSD symptomatology. A traumatic event is characterized by extreme stress that overwhelms a person’s ability to cope, potentially causing stable disturbances in self-organization 4. Our results show that the most negative outcomes of trauma at the level of eating behavior psychopathology are related to the destructive effect of trauma on personal relationships with others, relationship with self, and emotional regulation skills rather than to traumatic symptoms 28. Boredom, shame, and guilt also correlate more strongly with self-organization disorders than with classic PTSD symptoms. All these emotional states can play a relevant role in binge eating episodes 16,29,30. From the multiple linear regression conducted using binge eating symptomatology as the outcome variable, it appears that DSO symptoms were the best predictors among those included and that shame and boredom also significantly predicted binge eating behaviors. The psychopathological manifestation of trauma at the eating level can be motivated by the fact that food can represent a reward capable of temporarily increasing the mood 31. Negative states, like sadness or stress, increase theintake of hedonic foods 32. This result is in line with other studies in which hypersexual behavior was significantly predicted by trauma 33. Sex, as well as food, can be used as a mood regulator and a tool to cope with intolerable feelings 33.
Trauma and its consequences on emotion regulation difficulties (DSO cluster) may contribute to difficulties in getting out of a state of boredom. It was demonstrated that people with major pandemic trauma felt more bored, particularly when they lacked clarity about their emotions and struggled more to engage in purposeful behaviors when experiencing negative emotions 34. Boredom could, therefore, act as a trigger for uncontrolled eating behavior. Havermans compared the amount of food consumed by individuals engaged in a boring task versus a non-boring task, recording almost twice as much food consumption in the former group as in the second 35. This difficulty in getting out of boredom without resorting to dysfunctional behaviors could be exacerbated in individuals with difficulties in emotional self-regulation 34, which is one of the core symptoms of DSO.
Feelings of shame about the traumatic event may act as both a trigger and aperpetuating factor in BED. According to the emotion regulation model of BED, binge eating episodes may represent a dysfunctional coping strategy to attenuate negative emotions 36, this can be further exacerbated in individuals with high levels of disturbances of self-organization, who present difficulties in emotional self-regulation. Many individuals with BED report that distressing psychological states, including experiencing negative thoughts about oneself and feelings of worthlessness precede binge eating episodes 37. This use of dietary conduct as a strategy of self-medication may be related to emotional self-regulation difficulties associated with disturbances of self-organization, related to traumatic events, according to Mikhai’s theory about loss of control eating 38. Negative emotions trigger loss of control eating, and that loss of control eating is negatively reinforced because it temporarily decreases negative affect; the negative affect would decrease during binge eating episode rather than afterwards, and that episode of binge eating would replace one negative emotion with another that is less aversive 38. In this sense, the feelings of shame about binge eating behaviors or body weight may promote other binge eating episodes, perpetuating a cycle of shame and binge eating 39. Individuals with BED face stigmatization and subsequent shame associated with the disorder itself 30. They also often report that their behaviors are perceived as a problem of poor self-control, a perception that may be internalized, perpetuating feelings of shame 40. This is also in line with some findings from emerging literature on borderline personality disorder and night eating. Emotional instability in borderline personalities often aggravates compulsive behaviors, including binge eating and night-eating 41. The interplay between night-eating behaviors and depressive symptoms may depend by the maladaptive eating behavior that is developed as a coping response to negative affect or poor sleep quality 42. Sleep disruptions may further compromise mood regulation and intensify binge eating tendencies and could therofore be interesting to examinated in the future linked to disturbances of self-organization 43.
The lack of significance of guilt as a predictor of binge eating, in contrast to the significance of shame, can be explained by the fact that shame is a more complex intrapsychic process than guilt because it involves processes concerning the valuation of the core dimensions of the self, like identity, ego, and personality. In posttraumatic shame, the focus of evaluation concerns moral virtue, the goodness of the self, and the need to cope with feelings of disgrace, disrepute, loss of self-esteem, loss of virtue, and personal integrity. Guilt, on the other hand, concerns different forms of self-recrimination about responsibility for personal actions 11. Although unpleasant, guilt supports and enforces life-sustaining personal and moral values and creates a sense of control by supporting the idea that there is order and meaning in the world while strengthening the value of reconciling with others and being forgiven for improper actions and failed enactments in traumatic situations 44. In previous studies, shame has been found more associated with mental health problems than guilt 45 ; whereas shame is maladaptive, guilt may not be 46. To completely rule out the role of guilt and confirm the results of this study, it would be useful to replicate it with a clinical sample of patients treated for issues related to BED. Mediation analysis shows that self-organization disorders are associated with dysregulated eating behavior both directly and indirectly through related negative affective states. Shame and boredom are significant mediators of the relationship. This result may suggest that self-organization difficulties are often associated with uncontrolled eating behaviors and that negative emotions, such as boredom and shame, could act as triggers for such behaviors, explaining a relevant part of this relationship.
Limitation
The sample of this study is unbalanced by gender and age, a fact that should not be underestimated given the greater susceptibility to psychopathological manifestations related to eating behavior in the female gender 47. Due to the gender imbalance and the lack of a clinical sample, the study has limitations in the generalisability of the results. The snowball sampling methodology may also have caused sample selection bias. As mentioned in the discussion, to confirm the results of this study could be useful a replication protocol on a clinical population with BED. In addition, some of the traumatic experiences reported by the participants echoed highly stressful and negatively impactful experiences but did not involve events that had led to death or involved threats to one’s own or loved ones’ physical integrity.
Conclusion
In conclusion, our investigation found a relationship between traumatic experiences and binge eating symptomatology, describing a pathway involving shame and boredom. Self-organization disorders are involved in the relationship between traumatic experiences and binge eating more than the classic PTSD symptoms. Boredom and Shame can act as triggers for the binge eating episode. Clinical interventions in cases of traumatic events should be aimed primarily at improving personal emotional self-regulation skills and particularly at managing boredom and shame, emotional states that are predictive of binge eating episodes. In this sense, the aim of clinical intervention should be to replace binge behaviour in response to shame and boredom with adaptive behaviour. In the case of boredom, this should involve stimulating the subject’s creativity, and in the case of shame, it should involve working on self-esteem.
Aknowledgments
The authors would like to thank all the University students who participated at data collection for this study.
Funding
This research is supported by PRIN 2022 (project number: 20224SX547), and PRIN 2022 PNRR (project number: P2022ARREH).
Conflict of interest statement
The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Data and code
The data that support the findings of this study are available from the corresponding author, Giacomo Ciocca, upon reasonable request.
Author contribution
DD contributed to conceptualization, data curation, formal analysis, investigation, methodology, resources, software, visualization, writing the original draft, and editing the paper after the reviews. GO contributed to the project administration and reviewed the paper. TG reviewed the paper. EC contributed to the conceptualization and reviewed the paper. ADC reviewed the paper. EL contributed to the conceptualization, project administration, and supervision and reviewed the paper. LF contributed to conceptualization, data curation, methodology, resources, supervision, validation and reviewed the paper. GC contributed to conceptualization, data curation, funding acquisition, investigation, methodology, project administration, resources, supervision and reviewed the paper.
Figures and tables
FIGURE 1. Path plot. a DSO=disturbances of self-organization, MSBS=boredom, SHAME=shame, BES=binge eating behavior.
| N=1025; AGE 29.6 ± 10.9. | N | % | |
|---|---|---|---|
| GENDER | |||
| Woman | 731 | 71.3 | |
| Man | 294 | 28.7 | |
| NATIONALITY | |||
| Italian | 999 | 97.5 | |
| Not Italian | 26 | 2.5 | |
| SEXUAL ORIENTATION | |||
| Heterosexual | 866 | 84.5 | |
| Bisexual | 64 | 6.2 | |
| Homosexual | 95 | 9.3 | |
| RELATIONSHIP STATE | |||
| Single | 351 | 34.2 | |
| In a relationship | 674 | 65.8 | |
| YEARS OF STUDY | |||
| <=13 | 460 | 44.9 | |
| 13<x<15 | 277 | 27 | |
| >=15 | 288 | 28.1 | |
| BMI | |||
| < 25 | 735 | 71.7 | |
| >=25 | 289 | 28.3 | |
| Mean | Std. Deviation | |
|---|---|---|
| BES | 10.026 | 7.487 |
| MSBS | 29.704 | 12.233 |
| SHAME | 7.540 | 3.965 |
| GUILT | 7.638 | 4.375 |
| PTSD | 9.308 | 5.805 |
| DSO | 8.952 | 5.676 |
| a PTSD=posttraumatic stress symptomatology, DSO=disturbances of self-organization, MSBS=boredom, SHAME=shame, GUILT=guilt, BES=binge eating behavior. | ||
| Variable | PTSD | DSO | MSBS | SHAME | GUILT | BES | |
|---|---|---|---|---|---|---|---|
| 1. PTSD | Pearson’s r | — | |||||
| 2. DSO | Pearson’s r | 0.419*** | — | ||||
| 3. MSBS | Pearson’s r | 0.343*** | 0.613*** | — | |||
| 4. SHAME | Pearson’s r | 0.366*** | 0.672*** | 0.560*** | — | ||
| 5. GUILT | Pearson’s r | 0.308*** | 0.507*** | 0.393*** | 0.627*** | — | |
| 6. BES | Pearson’s r | 0.225*** | 0.420*** | 0.357*** | 0.357*** | 0.248*** | — |
| a PTSD=posttraumatic stress symptomatology, DSO=disturbances of self-organization, MSBS=boredom, SHAME=shame, GUILT=guilt, BES=binge eating behavior. | |||||||
| b * p<0.05. ** p<0.01. ***p<0.001. | |||||||
| Model | Unstandardized | Standard Error | Standardized | T | P | |
|---|---|---|---|---|---|---|
| H1 | (Intercept) | 2.951 | 0.570 | 5.172 | <. 001*** | |
| DSO | 0.354 | 0.054 | 0.269 | 6.550 | <. 001*** | |
| SHAME | 0.190 | 0.074 | 0.101 | 2.571 | 0.010** | |
| MSBS | 0.083 | 0.022 | 0.136 | 3.704 | <. 001*** | |
| a Dependent Variable: BES=binge eating behavior. DSO=disturbances of self-organization, MSBS=boredom, SHAME=shame | ||||||
| b * p<0.05. ** p<0.01. ***p<0.001. | ||||||
| Estimate std. | Std. Error | p | ||
|---|---|---|---|---|
| Total effect | DSO→BES | 0.074 | 0.005 | <0.001*** |
| Direct effect | DSO→BES | 0.047 | 0.007 | <0.001*** |
| Indirect effect | DSO→BES | 0.027 | 0.005 | <0.001*** |
| DSO→MSBS→BES | 0.015 | 0.004 | <0.001*** | |
| DSO→SHAME→BES | 0.012 | 0.005 | 0.01** | |
| Residual covariances | MSBS→SHAME | 0.148 | 0.019 | <0.001*** |
| a PTSD=posttraumatic stress symptomatology, DSO=disturbances of self-organization, MSBS=boredom, SHAME=shame, GUILT=guilt, BES=binge eating behavior. | ||||
| b * p<0.05. ** p<0.01. ***p<0.001. | ||||
