Contents lists available at ScienceDirect Eating Behaviors journal homepage: www.elsevier.com/locate/eatbeh Chew and Spit (CHSP): An interpretative phenomenological analysis (IPA) Phillip Aouad a,b,d, ⁎ , Arshia Morad a , Phillipa Hay c , Nerissa Soh e , Stephen Touyz a , Paul Rhodes a a School of Psychology, University of Sydney, Sydney, Australia b InsideOut Institute, Faculty of Medicine, University of Sydney, Sydney, Australia c Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith, Australia d School of Medicine, Western Sydney University, Penrith, Australia e Honorary Associate, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia ARTICLE INFO Keywords: Chew and spit CHSP Adolescents Health related quality of life Oral expulsion syndrome Eating disorder, Anorexia, Bulimia, EDNOS, OSFED, abnormal eating C/S, chewing and spitting CaS ABSTRACT Chew and Spit (CHSP) is a prevalent disordered eating symptom and has been thought to be associated with a number of adverse effects. In the current study, 18 participants (> 90% female, aged between 18 and 51) took part in answering questions about their experiences, struggles, concerns, methods of coping, and personal meaning of CHSP and how it has impacted their lives. Data collection and analysis were conducted in accordance with Interpretative Phenomenological Analysis (IPA) methodology. Findings revealed 7 primary themes of CHSP, which highlighted that CHSP may be: (1) associated with negative emotions - primarily shame; (2) ex- acerbated by stress and may be a mechanism to help regain control; (3) temporarily provides pleasure; (4) a distraction or form of escapism; (5) a self-soothing or coping mechanism; (6) addictive, ritualistic, and similar to other eating disorders in that it can become part of an individual's self-identity; and (7) adversely impacting psychological, physiological, and social health. Some of the identified superordinate themes were in line with previous studies hypotheses. However, overall the findings indicated that individuals who CHSP are often em- broiled in what they may perceive as a struggle, with no specific, efficacious, approach to helping them control the behavior. Future studies should focus on the treatment of CHSP, including treatment of CHSP as a potential primary symptom of pathological eating. Moreover, the perceived implications of engaging in CHSP should be examined more closely, with clinicians screening for the behavior and carefully considering their approach when attempting to treat patients for CHSP. 1. Introduction Chew and Spit (CHSP) has been identified as a symptom of dis- ordered eating in several studies using eating disordered patients as the primary focus (De Zwaan, 1997; Durkin et al., 2014; Guarda et al., 2004; Kovacs, Mahon, & Palmer, 2002; Makhzoumi et al., 2015; Song, Lee, & Jung, 2015). However, a recent study of CHSP in a community sample of adults found a prevalence of 0.4% and that CHSP was asso- ciated with subjective loss of control, laxative misuse, and fasting for prolonged (> 8 hoursh) periods of time in order to influence body weight or shape (Aouad, Hay, Soh, & Touyz, 2018). More concerning is CHSP among adolescents, as a recent study found a prevalence of > 10% (Aouad et al., 2019). Prior to the DSM-5, CHSP was included as a symptom in the “Eating Disorders Not Otherwise Specified” (EDNOS) category of the DSM (American Psychiatric Association, 2013), in part possibly due to the lack of information and prevalence data on the topic at the time. However, the latest findings indicate that the behaviour is more pre- valent than expected. Thus, clinicians need to be informed that CHSP is a symptom of disordered eating that may go unnoticed if not explicitly screened for. Further, there may be disagreement as to how to treat CHSP behavior given that it is poorly understood. In order to under- stand and ultimately develop effective treatments for CHSP, it is im- portant to gain insight into individual perspectives of the behavior. Given the lack of knowledge concerning CHSP, the current study aims to explore the phenomenon of the behavior as it relates to the lived experience of individuals. Accordingly, through the use of Interpretative Phenomenological Analysis (IPA; Smith, Jarman, & Osborn, 1999; Smith & Osborn, 2004), the current study aimed to ex- plore 1) how CHSP directly impacts individuals, 2) the challenges in- dividuals may face as a consequence of the behavior, 3) the burden individuals may associate with the behavior, 4) the function CHSP may https://doi.org/10.1016/j.eatbeh.2020.101388 Received 7 August 2019; Received in revised form 10 April 2020; Accepted 13 April 2020 ⁎ Corresponding author at: School of Psychology, University of Sydney, Sydney, Australia. E-mail addresses: phillip.aouad@sydney.edu.au (P. Aouad), amor3918@uni.sydney.edu.au (A. Morad), p.hay@westernsydney.edu.au (P. Hay), nerissa.soh@sydney.edu.au (N. Soh), stephen.touyz@sydney.edu.au (S. Touyz), paul.rhodes@sydney.edu.au (P. Rhodes). Eating Behaviors 37 (2020) 101388 Available online 27 April 2020 1471-0153/ © 2020 Elsevier Ltd. All rights reserved. T