RESEARCH ARTICLE

A Systematic Review of Impulsivity in Eating Disorders

Samantha E. Waxman*
Department of Psychology, Queens University, Kingston, Canada

Abstract The purpose of this paper is to conduct a systematic review of the current literature that examines impulsivity in individuals with eating disorders (ED). Studies were obtained from Embase, Pubmed and Psycinfo, and were included if they assessed impulsivity in individuals over 18 years of age with an ED diagnosis and published in the last 10 years. The methodological quality of the studies was rated. Twelve studies were included in this review, with methodological quality varying across studies. Findings suggest that impulsivity is best assessed multi-modally, with a combination of self-report, behavioural and physiological measures. In general, impulsivity was found to differentiate individuals with EDs from controls, as well as across diagnostic subtypes. The current ndings have important clinical implications for our understanding and treatment of both impulsivity and eating disorders. Copyright # 2009 John Wiley & Sons, Ltd and Eating Disorders Association.

Keywords eating disorder; impulsivity; review *Correspondence Samantha E. Waxman, Department of Psychology, Queens University, Kingston Ontario, Canada, K7L 3N6. Email: 4sew@queensu.ca

Published online 22 June 2009 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/erv.952

Introduction
A growing body of literature suggests that eating disorders (EDs), and, in particular, EDs in which bingeing features are present, are associated with impulsivity. Likewise, other forms of psychopathology, which often present in EDs have been associated with impulsivity. For example, substance abuse, interpersonal violence, impulsive shopping, stealing, promiscuity and repetitive suicidal gestures or attempts are considered impulsive because of the inherent disregard for the associated long-term consequences (Lowe & Eldredge, 1993). Impulsivity is a multidimensional concept that involves an impulse, the behavioural expression of that impulse, and the situation in which both occur (Coles, 1997, p. 181). Although, ED researchers have not implemented a standard operationalization of impulsivity, a variety of behaviours have been frequently identied as impulsive in nature. In most studies, impulsive behaviours are thought to be performed
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without conscious judgment, and characterized by acting on the spur of the moment, the inability to focus on a specic task, and a lack of adequate planning (Moeller, et al., 2001). Additionally, personality factors, such as sensation-seeking or risk-taking, have been included in denitions (Eysenck & Eysenck, 1991). In their review, Lowe and Eldredge (1993) found a higher prevalence of impulsive behaviours among binge eaters (BN, ANP) as compared to controls. More recently, self-injury (Favaro & Santonastaso, 1998), stealing (Vandereycken & van Houdenhove, 1996), sexual promiscuity (Wiederman & Pryor, 1996) and substance abuse (Holderness, Brooks Gunn, & Warren, 1994) were linked to the binge/purge subtypes of AN and BN. Higher impulsivity in individuals with EDs also has been associated with severity of ED symptoms (Favaro et al., 2005), Cluster B personality disorders (Steiger & Bruce, 2004), decreased psychological (Duncan et al., 2005; Favaro et al., 2005) and personality function ndez-Aranda, ing (Wonderlich et al., 2005; Ferna

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nez-Murcia, Alvarez-Moya, Granero, Vallejo, & Bulik, Jime 2006), distorted biochemical functioning (Steiger et al., 2001), less effective coping strategies (Nagata, Kawarada, Kiriike, Iketani, 2000b) and poor treatment outcomes and long-term prognosis (Keel & Mitchell, 1997; Sohlberg, Norring, Holmgreen, & Rosemark, 1989). Although impulsivity is a broadly dened concept, Dawe and Loxton (2004) recently factor analysed several well-established self-report measures of impulsivity and identied two independent factors: Reward sensitivity and rash spontaneous impulsivity (Dawe & Loxton, 2004). These factors are consistent with two models of impulsivity drawn from animal research (Swann, Bjork, Moeller, & Dougherty, 2002). Reward discounting corresponds with the reward sensitivity factor and involves the inability to delay reward, leading to an increased tendency to choose immediate small rewards over larger delayed ones (Monterosso & Aimslie, 1999). Rapid response corresponds with the rash spontaneous impulsivity factor and involves responding without adequate assessment of context (Evenden, 1999b). In addition to self-report measures, computer-based tasks also have been developed to assess these factors of impulsivity (Swann et al., 2002). The interpretation of the ED literature also is challenged by differences in the operationalization of impulsivity across studies, with several overlapping denitions being used (Evenden, 1999a). For example, the terms lack of control, lack of deliberation, excitementseeking, novelty-seeking, lack of self-discipline and venturesomeness have been used to describe impulsivity-related constructs (Claes, Vandereycken, & Vertommen, 2005). Adding to this problem is the issue of how impulsivity is measured in the ED literature. Studies assessing impulsivity in individuals with EDs have mostly relied on self-report measures (Claes, Nederkorn, Vandereycken, Guerrieri, & Vertommen, 2006), and only recently have more authors begun to use more objective measures (e.g. behavioural and physiological methods) to investigate impulsivity in those with EDs. Researchers also have studied individuals who exhibit a variety of impulsive behaviours, and proposed that there is a subgroup of ED individuals with a multiimpulsive syndrome (Lacey & Evans, 1986; Lacey, 1993; Fichter, Quadieg, & Rief, 1994). Persons with multiimpulsivity display several impulsive behaviours (e.g. stealing, substance abuse) in addition to binge eating; while individuals with uni-impulsivity have binge eating as their only behaviour that could be described

as impulsive. Multi-impulsive bulimia (MIB) is often dened by the existence of at least three (Fichter et al., 1994; Lacey, 1993) of the following behaviours: Alcohol or drug abuse, suicide attempts, repeated self-mutilation, sexual disinhibition or shoplifting. Fichter et al. (1994) studied women diagnosed with BNP and found that the MIB group had greater comorbid psychopathology and lower psychosocial functioning. This nding led the authors to conclude that MIB constitutes a distinct subgroup of individuals presenting with BN that is indistinguishable in terms of disordered eating symptoms but differs with regard to concurrent psychopathology. This group also has been shown to have higher study dropout rates than female controls (Newton, Freeman, & Munro, 1993), and poor treatment outcomes (Sohlberg et al., 1989). Unfortunately, Fichter et al.s (1994) criteria are not always used to assign MIB, which has led to a range of differences in criteria between studies (Bell & Newns, 2002). The purpose of the current paper is to systematically review the literature examining the relationship between impulsivity and EDs. Specically, this paper aims to summarize and critique the existing studies on impulsivity in EDs, synthesize the ndings in the literature, and highlight clinical implications and future research directions. The current review provides a single source for the reviewed information, and may help inform assessment and treatment considerations for individuals with anorexia nervosa and bulimia nervosa. The current paper expands on previous reviews (e.g. Lowe & Eldredge, 1993) by: (1) including the most recent research conducted in this area; and (2) systemically rating the quality of the studies. The specic questions addressed were: 1. How is impulsivity in EDs currently assessed? 2. Does impulsivity differentiate disordered-eating populations from controls? 3. Does impulsivity differentiate between subtypes of AN and BN? 4. How do individuals with multi-impulsivity differ from individuals with uni-impulsivity? 5. What is the role of impulsivity in EDs?

Method
Literature search
The literature search included papers written in English that reported data on impulsivity in samples of
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individuals with anorexia nervosa and bulimia nervosa. The reviewed studies were obtained by searching the databases of Embase, Pubmed and Psycinfo using the keywords impulsivity, impulsive, eating disorders, anorexia nervosa and bulimia nervosa. The terms impulsivity and impulsive were each combined with all of the ED terms to search each database. Additional papers were obtained from reference lists in the publications found in the initial search.

Quality rating system

A scientic merit rating system was developed based on Eiser, Hill, and Vances (2000) methodological criteria to rate the quality of each study included in the current review. Study quality was evaluated on the following dimensions: (1) Presence of a control group; (2) matching of the control group; (3) representativeness of the sample; (4) denition of the ED sample; (5) reliability of instruments; (6) validity of instruments; (7) appropriateness of interpretations and (8) appropriateness of limitations. Each dimension was given a score of 1 if present or 0 if absent, and a total quality score was created by summing each dimension for a possible score of 08. The author extracted the data and rated the studies.

Study inclusion criteria

For this review, articles were included if the main purpose of the study was to assess impulsivity in individuals presenting with a recognized ED diagnosis. Papers were included on the basis of (1) year of publication: Studies were included if published between 1998 and April 2008; (2) language: English language papers only; (3) empirical: Papers had to provide empirical data and not just review previous studies; (4) published: Papers had to published in peer-reviewed journals; (5) age: Individuals over 18 years of age only and (6) ED diagnosis: Participants had to meet criteria for an ED using DSM-IV or ICD-10 criteria. As the purpose of this review was to examine the relationship between impulsivity in diagnosed ED groups using the strict and highly recognized criteria established by the DSM-IV or ICD-10, papers pertaining to binge eating disorder (BED) were excluded as BED is currently not included in the eating disorders section of the DSM-IV or ICD-10. Papers involving samples of individuals over 18 years of age were included in an attempt to obtain a more homogenous group of participants and avoid the potential confounds associated with development. In addition, the majority of papers obtained during the literature search focused on adults with EDs. No restrictions were placed on ethnicity or gender. Therefore, using the above criteria, 12 papers were identied for inclusion in the review, while 17 papers were excluded based on the established criteria (criteria 1: n 4; criteria 3: n 2; criteria 4: n 1; criteria 5: n 3 and criteria 6: n 7).

Results
Twelve studies met inclusion criteria and are summarized in Table 1. Of the included papers, 1 was from Australia, 2 from Belgium, 1 from Canada, 1 from Italy, 2 from Japan, 2 from Spain and 2 from United Kingdom. The majority of the studies were cross-sectional; however, one study measured changes in impulsivity, ED pathology and general psychopathology following a self-help intervention (Bell & Newns, 2002). The remainder of the results section has been divided into several sub-sections. Introduction section summarizes the characteristics of the studies, including sample sizes, ages of participants, recruitment methods and diagnoses of participants, Method section discusses the quality ratings of the studies, Results section explores the common limitations across studies and Discussion section answers the specic questions regarding impulsivity.

Study characteristics
The descriptive characteristics of the 12 reviewed studies are presented in Table 1. The mean age of participants with EDs ranged from 20.0 to 27.9, the mean age of control participants ranged from 20.1 to 30.0, and only three studies noted age ranges (Favaro et al., 2005; Kane, Loxton, Staiger, & Dawe, 2004; Myers, Wonderlich, Crosby, Mitchell, Steffen, Smyth, & Miltenberger, 2006). Sample sizes varied from 15 (Butler & Montgomery, 2005) to 554 (Favaro et al., 2005), with a mean across studies of 129 participants. Across all studies, only female participants were included in the statistical analyses. Most studies did

Data extraction
The following information was extracted from each study to ensure that the inclusion criteria were met and to aid the quality rating process described below: Sample demographics, ED diagnosis, type of sample, impulsivity assessment method, results and limitations.
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Table 1 Summary of studies included in the review Age/years (mean and SD) Control group: Y/N Type of sample Impulsivity assessment method Self-report: MIS MIB and non-MIB groups reported signicant improvement in all areas, except fasting behaviours Small sample size Did not measure multi-impulsivity post-treatment Small sample size Main Results Limitations

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Author and Date

Sample size & ED groups

Bell and Newns (2002)

N 46 46 BN

30 (no SD stated)

Community

Butler and Montgomery (2005) Self-report: I7 Behavioural: Bets 16 CPT AN scored lower than controls on both impulsiveness and venturesomeness. Groups did not differ on number of Bets 16 risky bets chosen or on CPT errors of omission. AN made more errors of commission with shorter latencies ANR were less impulsive than both ANP and BN Age:28.4 (8.3)

N 15 15

27.9 (9.9)

Y N 16

Inpatient undergrad

AN (ICD-10 diagnosis)

Claes et al. (2005)

N 146 46 ANR 50 ANP 50 BNP 23.0 (6.6) 21.7 (6.8) 22.7 (5.8) Y N 83 Age: 20.1 (3.1) In/out patients Self-report: I7 BIS-11 BIS/BAS Behavioral: Stop/go task

20.45 (5.28) 20.0 (6.76) 21.3 (5.58)

Inpatients

Self-report: NEO-PIR MALT ADP-IV

None noted

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Claes et al. (2006)

N 56 ANR 14 20 ANP 22 BNP

There were no signicant correlations between self-reported measures of impulsivity and behavioural measures ANP, BN and controls were signicantly more impulsive and inattentive than ANR Self-report: 66.7% of ED versus 94.4% controls were non-suppressors

None noted

az-Marsa D et al. (2008) 22.5 (4.8) Y N 28

N 52 100%

Inpatient healthcare prevention program

Small sample size

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(Continues)

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Table 1.
Age/years (mean and SD) Control group: Y/N Type of sample Impulsivity assessment method I7 BIS-11 Physiological: Blood samples Enhanced cortisol suppression in ED was signicantly associated with the severity of bulimic symptoms and with impulsive personality features Among EDs, impulsive and multi-impulsive participants were characterized by the presence of purging behaviour and by specic temperamental features ED groups scored higher than controls on several self-report and behavioural measures of impulsivity. Main Results Limitations

(Continued)

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21.9 (5.6) 23.7 (6.3) Age: 24.3 (4.2) Absence of stability measures for DST Total sample: 1261 years 23.9 (6.5) N Outpatient Self-report: SCID None noted Total: 1834 with most between 2130 Self-report: AUDIT I7 BIS/BAS Behavioural: CARROT Self-report: DIB-R EMA (daily diary) EDSDB Y N 21 Ads in magazine of peer support for BN Media Ads Limited sample size Cross-sectional 24.9 (7.2) N Clinical and community settings 55 of 125 participants met criteria for MIB. MIB were more likely to engage in self-damaging behaviours, risky sexual behaviours, stealing and drug/alcohol abuse and dependence Self-report: IBQ SCID-P MI was found in 2% ANR, 11% ANP, 18% BN, 2% controls 80% of BN with MI had a history of suicide attempts or self-mutilation history prior to onset of BN 22.3 (4.0) 25.0 (5.1) 22.6 (4.2) Y N 66 Age: 21.0 (3.0) Outpatient Nursing students

Author and Date

Sample size & ED groups

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9 ANR 14 ANP 29 BNP

Favaro et al. (2005)

N 554 183 ANR 65 ANP 244 BNP 62 BNNP

Kane et al. (2004)

23 BN/AA 22 BN

Myers et al. (2006)

N 125 125 BN

Exclusion of male participants Retrospective recall bias LCA: limited by the indicators selected to be used in the analyses Only self-report Sampling bias Did not match those with and without multi-impulsivity in terms of age, onset, ED diagnosis, body weight history

Nagata et al. (2000a)

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N 236 60 ANR 62 ANP 114 BNP

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(Continues)

Table 1.
Age/years (mean and SD) Control group: Y/N Type of sample Impulsivity assessment method Self-report: IBQ BN had more maladaptive coping strategies and less adequate coping strategies than other ED groups or controls Impulsive bulimics had signicantly higher emotion-oriented coping scores Associations between bulimic pathology and impulsive behaviours were specic to externally directed behaviours Other forms of comorbid general psychopathology were associated with internally directed impulsivity (e.g., self-harm) Motor impulsiveness was higher for binge groups Inattention was higher for ANR, ANP, BN compared to controls BN and ANP had tendencies toward more errors on behavioural measure Non-planning was only characteristic of BN None noted Only self-report Cross-sectional Main Results Limitations

(Continued)

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Author and Date

Sample size & ED groups

Nagata et al. (2000b)

N 156 43 ANR 42 ANP 71 BNP

21.2 (4.8) 24.5 (4.8) 22.6 (4.6)

Y N 97 23.4 (5.2)

Outpatient Nursing students and medical staff

as-Lledo Pen et al. (2002) Total: 21.2 (4.3) N Outpatient Self-report: IBS

N 30 10 ANP 20 BN

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Rosval et al. (2006)

N 114 18 ANR 17 ANP 79 BN

24.56 (10.21) 25.59 (7.71) 25.04 (6.42)

Y N 59 Age: 24.3 (6.2)

Outpatient Ads

Self-report: BIS-11 DAPP-BQ: sensation seeking scale Behavioural: Go/No go task

Control group based on absence of overt Axis I pathology

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Impulsivity in Eating Disorders Total score

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Table 2 Scientic merit rating system

The quality ratings for each of the 12 studies are presented in Table 2. The quality ratings ranged from 3 to 7, with a mean quality rating of 5.5. This indicates that, on average, the studies included over half of the
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Authors and date

Quality ratings

Bell and Newns (2002) Butler and Montgomery (2005) Claes et al. (2005) Claes et al. (2006) et al. (2008) az-Marsa D Favaro et al. (2005) Kane et al. (2004) Myers et al. (2006) Nagata et al. (2000a) Nagata et al. (2000b) as-Lledo et al. (2002) Pen Rosval et al. (2006)

Note.Indicates present (score 1); mean total score 5.5.

not specify the ethnicity of the participants; however, two studies identied the participants as Caucasian (Claes et al., 2005; Myers et al., 2006), and two studies identied the participants as Japanese (Nagata, Kawarada, Kiriike, & Iketani, 2000a; Nagata et al., 2000b). Recruitment of participants with EDs varied across the 12 studies, with 3 (25%) recruiting participants from inpatient clinics (Claes et al., 2005; Butler & Montgomery, az-Marsa , Carrasco, Basurte, Sa iz, Lo pez-Ibor, 2005; D & Hollander, 2008), 5 (42%) from outpatient clinics (Rosval, Steiger, Bruce, Israel, Richardson, & Aubut, as2006; Favaro et al., 2005; Nagata et al., 2000a; Pen , Vaz, Ramos, & Waller, 2002; Nagata et al., Lledo 2000b), 2 (17%) from both inpatient and outpatient clinics (Claes et al., 2006; Myers et al., 2006) and 2 (17%) from community advertisements (Bell & Newns, 2002; Kane et al., 2004). Of the 7 studies that included control participants, 3 (43%) recruited from schools (e.g. nursing students; Butler & Montgomery, 2005; Nagata et al., 2000a,b), 2 (29%) from advertisements (Rosval et al., 2006; Kane et al., 2004), 1 (14%) from a az-Marsa et al., 2008) healthcare prevention program (D and 1 (14%) did not specify (Claes et al., 2006). Overall, seven studies compared individuals with AN and BN, three studies examined only those with BN and as-Lledo one study examined only those with AN. Pen et al. (2002) included individuals with both ANP and BN, but grouped them together for the analyses. In terms of specic ED diagnoses, many of the studies broke down the clinical groups into diagnostic subtypes. More specically, seven studies included participants with ANR, eight studies included participants with ANP and one study did not break down the anorexia group (Butler & Montgomery, 2005). The lack of subgrouping was likely due to the fact that the authors utilized ICD-10 diagnostic criteria, which does not identify specic types of anorexia nervosa. Six of the studies reviewed included participants with BNP, one study included participants with BNNP (Favaro et al., 2005) and ve studies did not break down bulimia nervosa into subtypes (Bell & Newns, 2002; Kane et al., 2004; Myers et al., 2006; et al., 2002; Rosval et al., 2006). as-Lledo Pen

Are limitations appropriate?

Are the interpretations appropriate?

Are the instruments valid?

Are the instruments reliable?

Is ED sample well dened?

Is the sample representative?

Is the control group matched?

Is there a control group?

4 7 5 6 7 4 5 5 7 7 3 6

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characteristics that were considered indicative of sound methodology. Several papers grouped the total sample into different ED subtypes, allowing the reviewer to investigate differences in impulsivity across the groups. A requirement of the rating system was that authors had to report on the reliability and validity of the measures used if the psychometric properties were not well known. As such, all of the studies reported using reliable and valid instruments to measure ED behaviours, impulsivity and various personality dimensions. Additionally, none of the studies drew conclusions that extended beyond their data, and of the eight studies that mentioned limitations, all were appropriate.

Limitations
After reviewing the 12 studies, several common limitations were identied. The demographic data provided by the various authors were inadequate. Although age and gender of participants were provided in all studies, only four papers described the ethnicity of the participants (Claes et al., 2005; Myers et al., 2006; Nagata et al., 2000a,b), and no studies mentioned participants socioeconomic status (SES). This lack of descriptive data limits the generalizability of the ndings, as ethnicity and SES are known to be important demographic factors in ED (Nevonen & Norring, 2004; Pate et al., 1992). Another limiting factor is that of the 12 studies reviewed, only seven included a control group, and only four of those studies matched the control group to the ED sample. Age was used as the only matching variable in the majority of these studies; however, Claes et al. (2005) matched ED groups on several variables including marital status, educational level, employment status and living situation. In addition, studies which examine individuals with and without multi-impulsivity may benet from matching participants on variables such as eating disorder diagnosis, ED onset and body weight history (Nagata et al., 2000a). There also may have been a sampling bias in that participants recruited from the community may be less impulsive than those assessed during an inpatient stay. One previous study has found that there are no differences with regards to referral bias between clinical and community populations; however, two of the reviewed studies (Claes et al., 2006; Myers et al., 2006) included individuals from both community and clinical

settings but did not specify whether the two groups differed on variables of importance (e.g. severity of ED), potentially masking important clinical differences. Additionally, although EDs are more common in females, many males are also affected by EDs (Woodside, Garnkel, Lin, Goering, & Kaplan, 2001), and unfortunately, all of the studies excluded males from their analyses. As such, the extent to which the results from the reviewed studies correspond to the experiences of males with EDs is unknown. Lastly, several studies (Bell & Newns, 2002; Kane et al., 2004; Myers et al., 2002; Rosval et al., 2006) as-Lledo et al., 2006; Pen grouped all participants with BN together, and did not specify the type (i.e. binge/purge or non-purge). According to Favaro et al.s (2005) research, the factor that signicantly predicted the presence and number of impulsive behaviours was purging behaviour, with those in the non-purging BN group showing a lower prevalence of impulsive behaviours. These ndings suggest that when subtypes of BN are combined, important outcomes may be concealed. Although the quality of the studies, on average, was rated as adequate, there are still some important limitations to acknowledge in the ED literature examining impulsivity. In the majority of studies, demographic information was incomplete, control groups were not included or were not matched on appropriate variables, and studies only assessed impulsivity in females with EDs. These studies, however, still contribute to understanding the relationship between EDs and impulsivity and future research should make efforts to overcome these limitations.

How is impulsivity in EDs currently assessed? In the current study, 7 (58.3%) of the studies used only self-report measures to assess impulsivity, while the rest of the studies used self-report measures and either behavioural (n 4, 33.3%) or physiological (n 1, 8.3%) instruments. The most frequently used measures included the Eysenck impulsiveness questionnaire (I7) and the Barrett impulsiveness scale (BIS11). In general, all of the measures used have acceptable psychometric properties (i.e. good reliability and validity). Other methods for obtaining self-reported impulsivity in the reviewed studies included the use of subscales from other measures (i.e. eating disorders section of the SCID) and an ecological momentary assessment (EMA; Myers et al., 2006). The EMA
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assesses mood, ED behaviour and self-damaging behaviours on a momentary and daily basis using three types of daily self-report methods (i.e. signal contingent recording, interval contingent recording, event contingent recording). Although self-report instruments appear to be standard in the eld of impulsivity and EDs, it is important to acknowledge that social desirability and the possibility that participants lack insight into their current behaviours challenge the accuracy of participants responses. As such, much of the research on impulsivity and EDs is restricted by the inherent limitations of self-report measures. In addition to self-report measures, there is a growing interest in the development of tasks that provide a more objective measure of an individuals impulsivity (Kane et al., 2004). The current review examined four studies that included at least one behavioural measure of impulsivity in addition to measures of self-reported impulsivity. Among the tasks used in the studies that assessed impulsivity objectively, three were based on responsiveness to reward, and two were based on response inhibition. Although each of the studies used a different computer paradigm, all were based on the premise that laboratory-based tasks provide a measure of impulsivity that is free from an individuals biases (Enticott, Ogloff, & Bradshaw, 2006). However, it is important to note that a limiting factor of this type of assessment method is that behavioural tasks are usually administered in a relatively neutral environment, and do not take into account factors that may affect impulsivity (e.g. autonomic arousal; Enticott et al., 2006), and thus may have limited generalizability. In addition to computer-based objective measures of impulsivity, one recent study assessed a physiological indicator of impulsivity in women with EDs, specically the suppression of cortisol following the ingestion of dexamethasone, also known as the dexamethasone az-Marsa et al., 2008). DST suppression test (DST; D provides information regarding the functioning of the neurobiological stress response. Enhanced cortisol suppression in ED groups has been shown to be similar to that found in individuals with various personality disorders (e.g. avoidant, schizoid, self-defeating, passive-aggressive, schizotypal and borderline; Schweitzer, Tuckwell, Maguire, & Tiller, 2001), and may reect hypothalamic-pituitary-adrenal axis dysfunctions. However, DST does not provide stability measures and may be inuenced by external and internal state az-Marsa et al., 2008). variables related to stress (D
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It would not be entirely unexpected that different instruments yield different ndings, given the methodological differences in their assessment of impulsivity. For example, Butler and Montgomery (2005) found reduced self-reported impulsiveness and venturesomeness in participants with AN, while the results on the behavioural task (e.g. CPT) suggested fast and inaccurate, or impulsive, responding. Similary, Claes et al. (2006) found an absence of signicant correlations between self-reported and behavioural measures of impulsivity across ED subtypes. One hypothesis for this lack of association is that the behavioural measures are tapping slightly different aspects of impulsivity compared to the self-report and physiological measures, az-Marsa which were shown to be highly correlated (D et al., 2008). Parker and Bagby (1997) have suggested that the lack of ndings may reect the differing theoretical conceptualizations of the construct itself or instead, reect the multidimensional nature of impulsivity (Gerbing, Ahadi, & Patton, 1987; Malle & Neubauer, 1991). Consequently, the ndings from the reviewed papers suggest that impulsivity should be assessed using multiple methods, as each method may provide unique information regarding impulsivity in EDs.

Does impulsivity differentiate disorderedeating populations from normal controls? Seven studies included comparisons with non-eating disordered control groups. Based on the reviewed papers, there appears to be a continuum of severity on which the diagnostic groups can be placed with the binge groups showing more impulsivity than the control groups, who in turn, show more impulsivity than the restricting groups. More specically, the binge groups (i.e., ANP, BN) showed more motor impulaz-Marsa et al., 2008; Kane et al., 2004; siveness (D Rosval et al., 2006), inattention (Claes et al., 2006), stimulus-seeking (Rosval et al., 2006), reward responsiveness and fun-seeking (Kane et al., 2004) than controls on self-report measures. ANR participants, however, were less likely than controls to engage in behaviours that corresponded with impulsiveness (i.e. risk-taking regardless of the consequences) and venturesomeness (i.e. sensation-seeking with consideration for the potential risks; Butler & Montgomery, 2005; Claes et al., 2006). These ndings suggest that bingeing and restricting behaviours may be seen as lying on opposite ends of a spectrum of impulsive behaviours

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and that ED groups may be distinguished by the presence or absence of impulsive characteristics. In support of this hypothesis, Nagata et al. (2000a) found that individuals with BNP met criteria for multiimpulsivity more frequently than controls when using self-report instruments. Multi-impulsivity may be considered more severe, as it involves multiple impulsive features. Impulsive behaviours that were signicantly more prevalent in BNP included self-mutilation, suicide attempts, overdosing, wrist cutting, repeated shoplifting and sexual relationships with individuals not well known to the participant (Nagata et al., 2000a). In contrast to self-report measures, behavioural indicators of impulsivity do not consistently differentiate ED groups from controls. However, it is difcult to compare the ndings across studies as the diagnostic subtypes of the ED samples varied and each study used a different computer-based task. With regard to response inhibition, Claes et al. (2006) did not nd a signicant increase in disinhibition or lack of inhibitory control between controls and the ED groups. Butler and Montgomery (2005) found that individuals with AN displayed more impulsive behaviours on a continuous performance task (CPT) than the control group, which included making more errors of commission and responding with faster reaction times. Similar results were found by Rosval et al. (2006) using a Go/No Go task, such that mean commission errors in the punishment condition, which is thought to be maximally sensitive to problems of response inhibition, were higher for the binge groups than the control group. This difference, however, only reached statistical signicance for the ANP group. When examining responsiveness to rewards, again a discrepancy arises. For example, Kane et al. (2004) found that individuals with BN were more reactive to rewards than controls, while Butler and Montgomery (2005) did not nd differences on the number of risky bets chosen (Bets 16) between participants with AN and controls. It appears as though the behavioural measures of impulsivity are evenly divided between signicant and non-signicant ndings, which does not allow for denitive conclusions to be drawn. However, the physiological indicator of cortisol suppression showed that the binge groups had higher rates of cortisol az-Marsa et al., 2008). suppression than controls (D More specically, enhanced cortisol suppression in the binge groups was associated with severity of bulimic symptoms (i.e., bingeing/purging) and with impulsive personality features (e.g. borderline personality

az-Marsa et al., 2008). This disorder (BPD) features; D nding, in addition to the signicant behavioural results (e.g. Butler & Montgomery, 2005; Kane et al., 2004; Rosval et al., 2006), lends support to the idea that behavioural and/or physiological indicators of impulsivity may be able to differentiate ED groups from controls. However, the ndings need to be replicated in future research using consistent ED samples and objective instruments, as well as using larger sample sizes.

Does impulsivity differentiate between subtypes of AN and BN? Six studies included comparisons across diagnostic subgroups of EDs. As with control comparisons, the binge groups showed more impulsivity than participants with restricting AN. Favaro et al. (2005), however, found that individuals with ANR also show impulsive behaviours, but at lower levels than the binge groups. Again, the binge groups showed more motor impulsiveness, excitement seeking, less self-discipline and less deliberation compared to restrictors (Claes et al., 2005; az-Marsa et al., 2008; Rosval et al., 2006). Claes et al. D (2005) found signicant differences between the diagnostic subtypes of EDs with respect to ED symptoms, psychopathological symptoms, alcohol abuse, DSM-IV personality disorder traits and all four personality traits of the UPPS model (Whiteside & Lynam, 2001): Urgency, sensation seeking, (lack of) premeditation and (lack of) perseverance. More specically, individuals with ANR showed fewer antisocial and BPD traits and more obsessive-compulsive traits when compared to individuals with ANP and BNP. The binge groups also were more likely to show sensation-seeking or novelty-seeking (Claes et al., 2006; et al., 2002); while as-Lledo Favaro et al., 2005; Pen restricting anorexics tended to show higher persistence scores (Favaro et al., 2005). Non-planning was only characteristic of BN, with ANR and ANP displaying fewer non-planning tendencies (Rosval et al., 2006). Unlike the ndings with control groups, the majority of the behavioural and physiological indicators of impulsivity mirrored the self-report ndings for the diagnostic groups. For example, when compared to ANR on the Go/No Go task, the binge groups had tendencies toward more errors of commission, which are believed to be sensitive to problems of response inhibition. However, the results were only signicant for the ANP group (Rosval et al., 2006). With respect to
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cortisol, BNP and ANP had greater percent cortisol az-Marsa et al., 2008). suppression than ANR (D Favaro et al. (2005) were the only investigators to divide the BN group into both diagnostic subtypes: Purging and non-purging. They found that impulsive behaviours are not exclusively linked to binge eating, as the presence of purging behaviours also signicantly predicted impulsive behaviours. Moreover, the nonpurging group of BN individuals showed a lower prevalence of impulsive behaviours compared to the binge groups. This nding corroborates earlier observations of Garner, Garner, and Rosen (1993), that purging ED groups represent a more severe clinical presentation than non-purging groups. Taken together, binge eating appears to be associated with behavioural forms of impulsivity (i.e. urgency), but not necessarily with cognitive forms (e.g. nonplanning). For example, individuals with ANP demonstrated less non-planning but higher motor impulsiveness. In sum, individuals with ANP appear to have more in common with BN individuals as they share the tendency to display greater response disinhibition and produce more impulsive behaviours. These results suggest that impulsivity does not differentiate ED diagnosis (AN or BN), but rather the clinical presentation of individuals with EDs (e.g. bingeing/purging).

How do individuals with multi-impulsivity differ from individuals with uni-impulsivity? Among individuals who binge and purge, there is a subgroup of individuals who engage in a variety of impulsive behaviours, in addition to the bulimic activities. These individuals are labelled as having MIB. In a sample of 544 individuals with ANR (n 183), ANP (n 65), BNP (n 244), BNNP (n 62), Favaro et al. (2005) found that 55% showed at least one type of impulsive behaviour, 35% showed more than one type and approximately 13% showed more than three impulsive behaviours. A few of the impulsive behaviours signicantly differed among the four groups, which included: Suicide attempts, seeking out dangerous situations, running away, stealing and substance/ alcohol abuse. Although the authors reported that the number of different impulsive behaviours signicantly differentiated the four diagnostic subgroups, they did not report which of the four subgroups were signicantly more impulsive. As such, no conclusions can be drawn about the prevalence of multi-impulsivity within
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each of the ED subgroups. In addition, the authors did not specify the number of impulsive behaviours that must be present for the individuals to be classied as multi-impulsive. Nagata et al. (2000a) assessed the prevalence of multiimpulsivity among 60 Japanese women with ANR, 62 with ANP, 114 with BNP and 66 controls. Self-report instruments were used to assess the presence of impulsive behaviours and traumatic childhood experiences. Using Fichter et al.s (1994) criteria for multiimpulsivity, 2% of ANR, 11% of ANP, 18% of BNP and 2% of controls met criteria. Similarly, Myers et al. (2002) used Fichter et al.s (1994) criteria to nd the lifetime prevalence in their sample of individuals with BN (no subtypes specied). Of the 125 participants, 55 (44%) met criteria for MIB and were more likely to engage in parasuicidal self-damaging behaviours such as driving intoxicated, risky sexual behaviours, stealing and drug/alcohol abuse and dependence. The authors suggest that the higher rate of MIB in their study may be inuenced by their recruitment method, which included community and clinical groups. Bell and Newns (2002) classied 11 (24%) of the BN participants as multi-impulsive using a somewhat different criterion; an individual had to report bingeing and two or more non-food items from the multi-impulsivity scale (e.g. shoplifting, promiscuity, self-harm). Nagata et al. (2000a) were also interested in exploring the temporal relationship between impulsive behaviours and the onset of EDs in bulimic individuals with and without multi-impulsivity. There was a tendency for individuals with MIB to start showing impulsive behaviours before the development of ED symptoms. The age of self-mutilation and suicide attempts in participants with MIB was signicantly younger than that in BNP participants without multi-impulsivity. More specically, 80% of individuals with MIB engaged in self-mutilation or suicide attempts before displaying ED symptoms, whereas 78% of individuals with BNP without MI had the full syndrome of ED before the occurrence of self-mutilation or suicide attempts. This nding indicates that the impulsive behaviours of individuals with MIB are not necessarily the result of disordered eating behaviours, and may be the expression of a more fundamental psychopathology. As with Fichter et al. (1994), Myers et al. (2002) did not nd any differences in daily ED behaviours between participants with and without multi-impulsivity. Likewise, Nagata et al. (2000a) found that multi-impulsivity was

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not associated with greater severity of eating disturbance, such as duration of ED, and current and minimum body mass index. Multi-impulsivity was, however, associated with childhood parental loss (i.e. parental death, divorce or separation), a nding mirrored by Myers et al. (2002) in that participants with MIB were more likely to have been physically, sexually and emotionally abused as children. Individuals with MIB have also been shown to have higher levels of anxiety disorders, specically PTSD and OCD (Myers et al., 2002), as well as depression (Bell & Newns, 2002). The differences between those with and without MIB suggest meaningful differences in etiology and pathophysiology. It also is possible that MIB results from traumatic experiences, and that bingeing and purging behaviours are used to regulate affect (Wonderlich et al., 2001). One recent treatment study assessed the effectiveness of a supervised self-help program for individuals with MIB compared to those without MIB (Bell & Newns, 2002). Those with MIB reported higher levels of depression at pre-treatment, but not bulimic behaviours. Although both groups experienced signicant decreases in depression and bulimic behaviours, the MIB group remained moderately to severely depressed and their bulimic symptoms remained at subclinical levels. The nding that the MIB group continued to present with elevated depressive and bulimic symptoms suggests that this group is likely at higher risk for relapse (Keller, Herzog, Lovori, Bradburn, & Mahoney, 1991; Mussell, Mitchell, Crosby, Fulkerson, Hoberman, & Romano, 2000). Unfortunately, the authors did not reassess impulsivity post-treatment, which would help draw conclusions regarding the effectiveness of supervised self-help for the management of other impulsive behaviours. Although, it is difcult to compare results across studies due to the inconsistencies in dening multiimpulsivity (for a more detailed review of MIB, see Bell & Newns, 2002), the results do suggest that multi-impulsivity exists in ED populations. These ndings support the idea that individuals with MIB do not differ from other bulimics in terms of ED behaviours, but do differ in terms of other impulsive or self-damaging behaviours, as well as in timing of ED onset, suggesting a different etiological process. As such, Fichter et al. (1994) have suggested that individuals with MIB should be classied as a distinct diagnostic group as they show additional

psychopathological features and are more challenging with regards to treatment and prognosis.

What is the role of impulsivity in EDs? Previous reviews of prospective data (Jacobi, Hayward, de Swaan, Kraemer, & Agras, 2004; Stice, 2002) showed that trait impulsivity does not consistently emerge as a risk factor for the development of an ED. It may be that impulsivity is only characteristic of a subgroup of individuals with EDs, or perhaps, it appears more strongly after the onset of the ED (Bruce & Steiger, 2005). Unfortunately, there have been very few studies that have used a longitudinal design to examine impulsivity as a risk factor for the development of EDs. Among existing longitudinal studies, samples consist of adolescents who, because of developmental factors, tend to have difculty with reective selfevaluation that is characteristic of personality inventories (Wonderlich, Connolly, & Stice, 2004). When examining samples of adolescent females, Wonderlich et al. (2004) found that delinquency (a behavioural construct thought to reect impulsivity) was a risk factor for the onset of ED behaviour. Delinquency is different in focus from the more commonly observed ED risk factors (e.g. dieting, thinness ideal internalization and body dissatisfaction; Stice, 2002), which suggests that externalizing behaviours may also be a risk for ED behaviours (Wonderlich et al., 2004). This hypothesis is supported as-Lledo in the current review by the ndings of Pen et al. (2002) that bulimic pathology was more specically linked with externally directed impulsivity (e.g. theft, reckless driving) in adult females. In support of the hypothesis that impulsivity is a risk factor for EDs, Nagata et al. (2000a) explored the temporal relationship between the onset of EDs and the occurrence of impulsive behaviours. As previously reported, eighty percent of BNP individuals with multiimpulsivity engaged in impulsive behaviours (i.e. suicide attempts, self-mutilation) prior to the development of the ED. These results suggest that the selfharming impulsive behaviours of those with multiimpulsivity are not necessarily the consequence of disordered eating behaviours, but instead may precede the onset of ED, denoting risk for the development of EDs (Nagata et al., 2000a). Upon examination of the various predictors of impulsive behaviours in individuals with EDs, the
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presence of impulsive behaviours was found to be associated with higher levels of psychiatric symptoms and eating pathology. More specically, maturity fears (from the eating disorder inventory) emerged as a signicant predictor of both the incidence and number of impulsive behaviours. These individuals described themselves as more childish, immature and fearful of growth. These feelings of immaturity may be a result of their impulsivity, which makes it more challenging to manage life problems and to be recognized by others as an adult. On the other hand, impulsive behaviours may be an expression of the challenges that the individual faces in adolescence that eventually leads to the development of an ED (Favaro et al., 2005). Childhood abuse also was predictive of impulsive behaviours, in that early traumatic experiences may lead to the development of affective dysregulation and inadequate control of impulsive behaviours (Favaro et al., 2005). Additionally, the presence of maternal psychiatric history was found to predict impulsive behaviours in those with an ED. This variable may suggest a genetic predisposition for developing impulsive behaviours in those with an ED or it may represent the lack of an adult role model during adolescence when one is forming a personal identity (Favaro et al., 2005). Although there remains little doubt that impulsivity and EDs are connected, the results are still inconclusive regarding the timing of ED onset and presentation of impulsive behaviours. Based on the current literature review, there are two probable models to explain this relationship. The rst model posits that impulsivity is a predisposing causal factor in the development of EDs, specically those with bingeing/purging behaviours, in addition to the other biological, psychological and social factors known to predispose an individual to develop an ED. The second model proposes that impulsivity acts as a moderator such that it inuences the expression of ED behaviour. More specically, various biological, psychological and social factors lead to the development of AN or BN. Regardless of ED type, however, individuals with a tendency towards impulsivity will be more likely to engage in binge/purge behaviours. Given the ndings from the current review, the second model seems more appropriate. For example, individuals with AN develop either the restricting or binge/purge type. Those with ANP appear to be more similar to individuals with BN, and consistently show more impulsivity than controls and those with ANR. These models are untested, and more
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research is needed to ascertain the specic role of impulsivity in EDs.

Discussion
The purpose of the current paper is to systematically evaluate the most recent literature examining impulsivity in adults with EDs. Of the 12 studies that met criteria, methodological quality was adequate; however, several limitations were identied. Several ndings emerged from this review. First, there is no single way to measure for impulsivity so assessments should be approached multi-modally, including self-report, behavioural and physiological measures. Second, women with EDs, particularly the binge/purge types, show more impulsive behaviours than controls. Third, impulsivity was not found to differentiate the specic ED diagnosis; however, it was found to differentiate individuals with AN and BN based on their clinical presentation (e.g. bingeing/purging). Third, several individuals with BNP display multiple impulsive behaviours, and may be at higher risk of relapse following treatment. Lastly, impulsivity may be a risk factor for the development of EDs in women. Despite the limitations of the reviewed papers and the need for future research, the ndings have important clinical implications for our understanding and treatment of both impulsivity and EDs.

Clinical Implications
As previously stated, impulsivity has been shown to consistently predict negative outcomes for individuals with EDs (e.g. Keel & Mitchell, 1997). More specically, research has shown that individuals with MIB show poorer prognosis and greater treatment consumption (Fichter et al., 1994). As such, it is important for health care providers to assess for the presence and number of impulsive behaviours in order to provide proper treatment for individuals with EDs, which may include addressing the underlying impulsivity rather than only addressing the ED behaviours. Given the often limited time and resources in health care settings, self-report questionnaires are an efcient way to evaluate impulsive behaviours (e.g. Claes et al., 2005; Claes et al., 2006; Kane et al., 2004; Rosval et al., 2006) and should be incorporated into initial assessments for ED services. If time and resources allow, it would be

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benecial to add a behavioural indicator of impulsivity to the assessment. Alternatively, impulsivity may be addressed during intake interviews with an experienced clinician. Additionally, it will be important for clinicians to address an individuals ability to cope with stressors as it has been speculated that impulsive behaviours (e.g. binge/purge, self-harm) may be the result of a maladaptive coping process (Nagata et al., 2000b). Bulimic and impulsive behaviours typically occur in response to stress, with the bingeing and/or purging alleviating the distressed feelings or negative affect. Using self-report instruments, Nagata et al. (2000b) found that individuals with BNP had signicantly lower task orientedcoping scores than controls, which involves solving problems, cognitively restructuring the problem, or attempts to alter the situation. Similarly, the emotionoriented coping scores of individuals with binge/purge subtypes, regardless of whether they were AN or BN, were signicantly higher than that of controls, with impulsive bulimics scoring signicantly higher than less impulsive bulimics. Emotional coping involves the presentation of emotional responses (e.g., anger, blame), self-preoccupation and fantasizing to modify a situation. Furthermore, the emotion-oriented scale was signicantly correlated with other measures of psychopathology (e.g. depression). These results suggest that when an individual engages in one impulsive behaviour, it provokes another maladaptive impulsive behaviour as a result of using maladaptive strategies to cope. Therefore when treating individuals with EDs, particularly binge/ purge types, it is important to emphasize the use of adaptive coping strategies to manage stressors (Nagata et al., 2000b). Individuals with ANR require a different focus in treatment. For example, although few individuals with ANR are able to restrict their eating for prolonged periods of time, previous research has suggested that many individuals experience a breakdown of this hypercontrol and move to ANP, followed by BN (Keel, Dorer, Franko, Jackson, & Herzog, 2005). Given this nding, Butler and Montgomery (2005) suggest that levels of self-control and impulsivity can change over time, which has important implications for treatment. For example, the authors have recommended monitoring an individuals impulsivity over time to watch for changes in presentation. The focus of this clinical intervention would be to address self-control and impulsivity without specically having to discuss eating

behaviours, thereby reducing the possibility of resistance on the part of the client. Dialectical behaviour therapy (DBT; Linehan, 1993) is a useful therapeutic intervention for managing impulsive behaviours that are characteristic of BPD. DBT is a skills-based approach for teaching individuals general problem-solving skills, emotional regulation strategies, interpersonal skills and distress tolerance (Moeller et al., 2001). In particular, the mindfulness component of DBT plays an important role in helping individuals regulate their emotional instability and better tolerate emotional distress (Bruce & Steiger, 2005). Researchers recently have started to use DBT techniques in the treatment of EDs (Wisniewski & Kelly, 2003). For example, the DBT skills training model has been adapted and applied to the treatment of individuals with BN (Safer, Telch, & Agras, 2001) and BED (Telch, Agras, & Linehan, 2000; Telch, Agras, & Linehan, 2001). Palmer, Birchall, Damani, Gatward, McGrain, and Parker (2003) also evaluated a DBT program for comorbid eating disorders (BN and BED) and BPD. There were no dropouts from the program and most participants showed improvements in terms of disordered eating and self-harm behaviours at 18 months follow up. The results of these studies validate DBT skills training for decreasing symptoms in binge groups, and provide preliminary evidence that DBT is an effective model for the treatment of BN and BED. In addition, McCabe and Marcus (2002) argue that DBT is also effective at managing AN, particularly, when other front line forms of therapy have failed (e.g. refeeding, medical management, CBT, family therapy); however, little empirical support has been provided. Although, the current research on DBT for individuals with EDs looks promising, further research is needed comparing the effectiveness of DBT to other empirically supported treatments for managing impulsivity and eating behaviours. In addition to psychotherapy, the current ndings have implications for pharmacological treatment. As previously mentioned, impulsivity is a key feature of many other psychiatric disorders, including attention decit hyperactivity disorders (ADHD). The overlap in clinical characteristics and genetic risk factors between ADHD and BN suggest that the two disorders may respond to the same pharmacological treatments (Dukarm, 2005). Stimulant medications, including methylphenidate and dexotroamphetamine, are commonly used in the treatment of ADHD (Spencer,
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Biederman, Wilens, Harding, ODonnell, & Grifn, 1996), and may be appropriate for individuals with BN. Bulimic behaviour likely results from or is inuenced by impulsivity and therefore, decreasing impulsivity through the use of stimulants could potentially decrease bingeing and purging behaviours. Studies investigating the use of anti-depressants for women with BN have shown some reduction in the frequency of bingeing and purging; however, very few women have been able to completely abstain from engaging in bulimic behaviours (Mayer and Walsh 1998; Hughes & Wells, 1986). More recently, case reports evidencing the effectiveness of psychostimulant medications for reducing bulimic behaviours have begun to appear in the literature (e.g. Drimmer, 2003; Dukarm, 2005; Sokol et al., 1999). In one such study, six participants with BN were able to completely refrain from bingeing and purging following treatment with psychostimulants, and none of the women discontinued the medication because of side effects (Dukarm, 2005). These two ndings suggest that psychostimulants may be a useful treatment for the impulsive symptoms of women with BN. Unfortunately, there have been no randomized control trials evaluating the efcacy and tolerability of psychostimulants for treating BN. In addition, due to the absence of case reports on individuals with ANP, the ndings can only be applied to those with BN. Nevertheless, given the similarities noted in the current review between individuals with ANP and BN (both subtypes), it is hypothesized that pharmacological treatments may be benecial for both diagnostic subtypes. Due to the appetite suppressing effects of stimulant medication (Dukarm, 2005), however, it may be contraindicated for individuals with AN due to their already signicantly reduced body weight.

(i.e. DSM-IV, ICD-10). Upon inclusion of BED in the manuals, a review of the similarities and differences in impulsivity across diagnostic subtypes should be conducted. Lastly, none of the studies reported power or effect sizes, making it impossible to ascertain the appropriateness of sample sizes; therefore, power analyses could not be conducted due to lack of relevant data.

Future research
Based on the systematic analysis of scientic merit, the following are recommendations for improving the quality of studies used to assess impulsivity in adults with EDs: 1. Control groups need to be included and matched on multiple factors (i.e. age, gender, relationship status, ED severity, education level and ED onset). 2. Impulsivity ought to be assessed using valid and reliable instruments, which should be reported in empirical studies. Additionally, researchers should attempt to use combinations of self-report, behavioural and physiological measures when possible. 3. Studies should adequately describe sample characteristics to allow for generalizability of the ndings. This includes providing information regarding age, gender, ethnicity and SES. 4. As impulsivity is shown to vary by diagnostic subtype, it is imperative that authors dene the ED sample accordingly. Upon reviewing the most recent literature on impulsivity in EDs, the following are recommendations for future research: 1. Attempts should be made to rectify some of the limitations associated with the instruments used to measure impulsivity. For example, behavioural and physiological measurements are often conducted in neutral environments but can be inuenced by az-Marsa et al., internal or external stress (e.g. D 2008; Enticott et al., 2006). Researchers might investigate impulsivity under conditions of cognitive or emotional stress by administering self-report and objective measures of impulsivity both before and after an anxiety-provoking situation to examine possible changes in impulsive behaviours. 2. It would be helpful to include other behavioural and physiological indicators of impulsivity. For example, the Stroop test may serve as a useful objective

Limitations of the current review

Although, the current review is an important addition to the literature on EDs, there are limitations that should be noted. First, a great deal of research examining risk factors associated with eating pathology focuses on adolescents. Given that the current review only included adults, it may be difcult to draw any rm conclusions regarding the role of impulsivity in the development of EDs. Second, individuals with BED were excluded from the review because the disorder is not currently included in the main diagnostic manuals
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measure of impulsive behaviour. Enticott et al. (2006) found that when participants needed more time to resolve the colour-word interference, selfreported non-planning, attention, motor and overall impulsiveness increased. 3. Additional treatment studies are needed where individuals are monitored for changes in impulsive and ED behaviours. It may be helpful to develop treatments that specically target impulsivity as a way of eliminating disordered eating symptoms (e.g. purging behaviours; Favaro et al., 2005). Future research should expand on current DBT and pharmacological studies, as well as explore other avenues for treatment. 4. All of the research reviewed focused only on impulsivity in females with EDs, excluding all males from analyses. Forthcoming studies should examine the presence and impact of impulsivity on eating behaviours in males suffering from EDs, as well as changes in impulsivity and ED behaviours following treatment.

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