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Anger Management: Cognitive Therapy Interventions
Anger Management: Cognitive Behavioral Interventions - 10 CEUs

Section 18
Association of Anger with Bulimic and Other Impulsive Behaviors

CEU Question 18 | CEU Answer Booklet | Table of Contents | Anger Management
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Anger is strongly associated with the eating disorders, especially among bulimic patients. The uncontrolled expression of anger is particularly common among bulimic individuals with high levels of impulsivity. Anger is associated with treatment dropout in the eating disorders and impulsive bulimics have a poor treatment outcome, stressing the potential importance of anger in this group. The link between anger and bulimia might be explained by the use of bulimic behaviors (especially binge-eating) to block awareness of negative emotional states. Baumeister, Heatherton, and Tice’s (1994) model suggests that other impulsive behaviors are functionally equivalent to binge-eating, in that all can reduce the awareness of intolerable affect.

The relationship between bulimia, impulsivity and anger is complicated by the fact that each is a multifactorial construct, involving a range of cognitive and behavioral characteristics. Bulimic behaviors involve binge-eating, purging and compensation (e.g. restriction and exercise). Anger can be understood in terms of a state, a trait, and behaviors such as expression and avoidance of the affect.  Milligan and Waller (2001) have shown that impulsive behaviors can be divided into those that are internally directed (e.g. self-harm, drug use, alcohol abuse, binge-eating) and those that are externally directed (e.g. theft, uncontrolled buying, risky sexual behaviors, risky driving). Furthermore, each of these constructs seems to show gender differences. Women are more likely to engage in: bulimia; self-harm; theft; uncontrolled buying; and risky, unprotected sexual encounters. In contrast, men are more prone to consume alcohol and marijuana and to engage in risky driving. The evidence regarding gender differences in anger is less consistent. Deffenbacher et al. (1996) failed to identify differences between men and women in the experience or expression of anger, and others show that apparent differences may be related more to gender role identification than to gender per se.

Since the eating disorders literature to date has focused largely on the links between anger and binge-eating, it is not clear whether this emotion is related to other eating behaviors (particularly restriction and purging). Nor is it clear whether the anger–bulimia links are specific to this eating behavior or whether they are reflective of a general association with impulsive behaviors. Equally, as most of the data about the multifactorial/complex relationship between bulimia, impulsivity and anger apply to female clinical populations with high comorbid psychopathology, the use of an explicitly homogeneous non-clinical group could shed some light on the origins of these links. Finally, given differences in these characteristics across males and females, it remains to be determined whether the associations of anger with bulimia and other impulsive behaviors apply equally to both genders.

Thus, the present study aims to clarify whether the relationship between anger and bulimia is specific to binge-eating rather than other eating behaviors or other impulsive characteristics. The second aim is to determine whether the links are gender-specific.

The participants were 131 undergraduate volunteers.  Of these, eight women and two men were excluded because they reported present or past treatment for any psychological problem, and/or did not complete the measures. Thus, the final sample consisted of 72 women and 49 men. The women’s mean age was 20.7 years (SD=2.10) and the men’s was 20.5 years (SD=2.20). Based on self-reports of height and weight, the women’s mean body mass index (weight[kg]/height[m]2) was 21.2 (SD=2.53) and the men’s was 22.7 (SD=2.32).

Measures and Procedure
The participants each completed Spanish translations of three self-report measures. The measures were completed in the order given below, as part of a broader assessment. In all cases, higher scores reflect more pathological attitudes and behaviors.  The participants also gave demographic details, and were asked to report any previous history of eating disorders or other psychological disturbances.

State–Trait Anger Expression Inventory (STAXI; Spielberger, 1996)
The STAXI is a self-report questionnaire, which measures the experience and expression of anger.  It consists of six primary scales, which have good psychometric properties. However, only three of those scales were used for the present study, as they remain valid following translation into Spanish.  The trait anger scale measures individual differences in the disposition to experience anger.

Anger suppression measures the extent to which angry feelings are held in. Externally directed anger measures how anger is expressed towards other people or objects in the environment. Participants rate themselves on four-point scales, assessing the frequency with which anger is experienced, expressed or suppressed.

Impulsive Behaviors Scale—Revised (IBS; Rossotto, Yager, & Rorty, 1994)
This self-report scale assesses the degree to which the individual uses 25 different impulsive behaviors.  The frequency of each behavior is rated on a five-point Likert-type rating scale. The items can be used to form two scales—those reflecting internally directed impulsive behaviors and those reflecting externally directed impulsive behaviors. The 11 internally directed impulsive behaviors (e.g. self-harm, alcohol abuse, drug abuse) are characterized by self-harm. In contrast, the 14 externally directed impulsive behaviors (e.g. theft, compulsive buying, unsafe sexual encounters) involve only an unintended risk of self-harm. Peñas-Lledó and Waller (2001) and Peñas-Lledó , Vaz, Ramos, and Waller (2002) have demonstrated the psychometric utility of the overall IBS scale in non-clinical British women and in clinical Spanish women. The internally directed and externally directed impulsive behavior scales had acceptable levels of internal consistency in this study (respectively, Cronbach’s alpha=0.73 and 0.79 for the women, and 0.70 and 0.78 for the men).

Bulimic Investigatory Test, Edinburgh (BITE; Henderson & Freeman, 1987)
This is a 33-item self-report questionnaire, which was developed to assess bulimic attitudes and behaviors.  Henderson and Freeman (1987) have shown the BITE to have strong reliability and validity. The questionnaire includes two subscales—symptoms, and severity. For the present study, three measures were derived from the BITE severity score—the reported severity of bingeing, of fasting and of purging behaviors (sum of the frequency of vomiting and the use of diet pills, laxatives and diuretics).

Data Analysis
Non-parametric tests were used throughout, due to skewed data. Gender differences in anger levels (STAXI), bulimic pathology (BITE) and impulsivity (IBS) were tested using Mann–Whitney tests. Anger measures were correlated (Spearman’s rho) with severity of eating behaviors and impulsivity.  Two-tailed tests were used throughout.

Women reported a greater severity of bingeing and purging behaviors than men. However, the men’s levels of both internally and externally directed impulsivity were higher than the women’s.

Among the females, trait anger was positively associated with the frequency of bingeing and negatively with the frequency of fasting. In contrast, it was associated with internally directed impulsive behaviors among men. The external expression of anger was correlated with the frequency of bingeing and impulsivity among both men and women.  However, the link was with externally directed impulsive behaviors among women but internally directed behaviors among men. Anger suppression was not associated with bulimic behaviors or impulsive behaviors for either males or females.

Table 1. Severity of bingeing, fasting and purging behaviors (BITE severity), anger (STAXI) and impulsivity (IBS) among non-clinical women and men





Women Mean

(N=72) (SD)

Men Mean

(N=49) (SD)



Eating behaviors (BITE)





















Purging behaviors







Anger (STAXI)







Trait anger







Externally directed anger







Anger suppression







Impulsivity (IBS)







Internally directed







Externally directed
















This study of a non-clinical sample has explored whether different aspects of anger are related to bulimia and other impulsive behaviors, and whether those links differ across males and females. While women showed higher levels of bulimic behaviors (bingeing and purging), the link with bulimic features was found particularly among those women who were more likely to experience angry feelings (i.e. high levels of trait anger). In contrast, the men’s higher levels of anger experience was associated with internally directed impulsive behaviors (such as substance abuse and self-harm).

External expression of anger was related to binge eating regardless of gender, but was associated with different facets of impulsivity for males and females.  The finding of an anger–eating link in the female population is consistent with the existing literature in clinical and non-clinical populations. Various authors have suggested that binge-eating may act to block awareness of negative emotional states. The general anger–impulsivity links found here provide indirect support to a model where impulsive behaviors serve this equivalent function.

However, the pattern of linkage shown here suggests that different behaviors are associated with anger among males and females. The finding of a link between the uncontrolled expression of anger and bingeing and impulsivity is consistent with existing research on female populations. These links might be explained from a temperamental perspective, where a personality pattern characterized by general impulsivity and affect dysregulation predicts bulimic attitudes, alcohol and drug use, risky sexual behavior and risky driving.

The specific association of externalized anger and internally directed impulsive behaviors (such as alcohol and recreational drug use) among males might be explained by alcohol-induced disruption of higher cognitive functions, and by alcohol’s anxiolytic and disinhibiting effects on the subcortical structures implicated in anger and aggression. Women may use alcohol to deal with different emotional states, such as anxiety and sadness. The absence of any link of anger suppression with impulsivity and bulimic characteristics does not provide support for the hypothesized role of such behaviors as emotional blocking agents. Yet, the absence of such a link in this non-clinical population may be an indication that anger suppression is a more prominent feature of restrictive disorders rather than impulsive problems.

Table 2. Correlations (Spearman’s rho) of anger (STAXI) with eating behaviors (BITE) and impulsivity (IBS) among non-clinical females (N=72) and males (N=49)

Anger (STAXI)












Eating behaviors (BITE)




























Impulsivity (IBS)







Internally directed







Externally directed







- Peñas-Lledó , Eva; de Dios Fernandez, Juan; Waller, Glenn.  European Eating Disorders Review, 2004.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #4
The preceding section contained information about the association of anger with bulimic and other impulsive behaviors among non-clinical women and men. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 18
In the Peñas-Lledó study, how did external anger expression in both genders relate to binge eating and impulsivity? Record the letter of the correct answer the CEU Answer Booklet.

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