Binge Eating: Current Science & Practice Gia Marson, Ed.D., & Danielle Keenan-Miller, Ph.D.
What is BED? Recurrent periods of eating more than others would in similar circumstances Perceived loss of control over eating At least 3 associated symptoms: Eating more quickly than normal Eating to discomfort Eating large amounts of food when not hungry Eating alone due to embarrassment Negative affect following binge episode Lack of compensatory behaviors DSM-5, APA, 2013
BED: What you need to know Most common ED 3.5% of women; 2% of men Can occur at any weight Associated with significant stigma Often overlooked by clinicians Many BED clients receive tx for other emotional problems but binge eating is not addressed Fear of stigma is most common barrier to tx Duarte et al., 2007; Hepworth & Paxton, 2007; Herman et al., 2014; Hudson et al., 2007; Kessler et al 2013
Differences from other EDs Does not require overvaluation of weight & shape Is more common among dieting individuals Presence is related to worse prognosis (Grilo, 2013) Later onset (mid 20s) Less gender discrepancy Hudson et al., 2007
How not to talk about BED Words to avoid: a bulimic a binge eater a bulimic episode binging or bingeing bulimia normal weight Use instead: individual with bulimia nervosa an individual with binge-eating disorder a binge-eating episode binge eating bulimia nervosa weight inclusive language range of shapes and sizes Tylka et al., 2014; Weissman et al.,2016 overweight
Current Understandings: Etiology
Dual Pathway Model Negative Affect Body Dissatisfaction & Shame Negative Food Cognitions Binge Eating Dietary Restraint Mason & Lewis, 2015; Stice, 1994
Emotion Regulation BE more prevalent among those with depression, anxiety, stress Affect-regulation theory Escape theory BE is associated with emotion-oriented coping and avoidance/distraction Spoor, Bekker, Van Strien & Van Heck, 2007
Transdiagnostic Model Low self-esteem Overvaluation of weight & shape Dieting Perfectionism Binge Eating Mood Intolerance Achieving in other domains Fairburn, Cooper, & Shafran, 2003
Neurobiology Genetic risk related to dopamine and opioid receptor genes Increased attentional bias to food Diminished activity in the brain systems that process rewards Some evidence for increased anticipation of reward, leading to a reward deficit Frank et al., 2016; Kessler et al., 2016
Confronting Weight Stigma Do no harm Medical concerns versus complicity with stigma disorienting limbo between too visible and invisible http://www.thisamericanlife.org/radio-archives/episode/589/tell-me-im-fat Handout #1 (This American Life; Shrill: Notes from a Loud Woman; Lindy West, 2016)
Shame & Stigma Weight stigma is common & predicts BE Even accounting for stress, coping, body dissatisfaction, other psychological distress Possible pathways: Coping Dieting/ social restriction Psychological distress Self-esteem depletion/ disrupted self-regulation Cortisol drives eating & fat storage Almeida, Savoy, & Boxer, 2011; Ashmore et al., 2008; Puhl & Huer, 2010; Tomiyama, 2014
Is it an addiction?? Gearhardt, Davis, Kuschner & Brownell, 2011
Is it an addiction? Similarities Loss of control Consuming more than intended Unsuccessful attempts to quit Role impairment Time consuming Cravings Some neurobiological similarities Tolerance? Withdrawal? Differences Not correlated with other forms of addiction Food s effect on the brain is weak & much less neurotoxic Food responses more diffuse in the brain Abstaining likely to be counterproductive Must make peace with eating Gearhardt et al., 2009; Gearhardt et al., 2013; Shulte, Grilo & Gearhardt, 2016; Smith & Robbins, 2012
Best Practices in BE Treatment: Cognitive Behavioral Therapy and Interpersonal Therapy
CBT: Challenging Overvaluation of Weight and Shape Fairburn et al., 2008
CBT: Regularizing Eating & Reducing Restriction What is normal eating? Handout #2
CBT: Non-Restrictive Structure 3 meals and 2-3 snacks daily Stop delayed eating No more than 4 hour interval between eating Contain eating Resist urge to binge eat behavioral skills (other activity, leave kitchen, etc.) psychological skills (tolerate and ride out urge) Monitoring (apps, paper) Murphy et al., 2010
CBT: Binge Eating Triggers Behavioral? Emotional? Physiological? Interpersonal? Fairburn CG. Eating disorders: the transdiagnostic view and the cognitive behavioral theory. In: Fairburn CG. Cognitive behavior therapy and eating disorders. New York: Guilford Press; 2008. (p. 7 22)
BE treatment vs. behavioral weight management - Often suggested by other providers - In general, BWM is not that effective - 1 in 1,290 men and 1 in 677 women met weight loss goals & most of those who did regained the weight (Fildes et al., 2015) - BWM is less effective among individuals with BED than similar weight individuals w/o BED - BWM is less effective in reducing binge eating than self-help CBT or IPT Grilo & Masheb, 2005; Korkeila, et al., 1999; Mann, 2007; Munsch et al., 2007; Wilson et al., 2010;
Confronting Resistance Role Play & Discussion Handout #3
IPT: Overview Directly addresses the interpersonal problems maintaining binge eating Indirectly addresses symptoms Time limited Current interpersonal problems rather than past problems Focus on the problem area and guide change: clarify, explore, decision-analysis, role play,communication analysis Murphy et al., 2012
IPT: Identifying the role of interpersonal problems 1. Lack of Intimacy, Interpersonal Deficits 2. Interpersonal Role Disputes 3. Role Transitions 4. Complicated Grief 5. Life Goals Murphy et al., 2012
Mental Rehearsal Research supports the use of visualization Similar to a safety plan for suicidal clients Handout #5
Tolerating Distress Accepting: distress comes from wanting something you don t have; treat the present moment and the past as fact (https://www.youtube.com/watch?v=-vcqecpmpzg, Linehan on Radical Acceptance, August 8, 2016) Self-soothing: using tools of seeing, hearing, smelling, touching, tasting for comfort Distracting: do something, contribute something, compare, or create other emotions/thoughts/sensations (Miller, Rathus, Linehan, DBT with Suicidal Adolescents, 2007)
Mindfulness - Goal is to have nonjudgmental attention to and acceptance of immediate experience - Delays automatic reactivity to allow choice - Can be broadly focused or focused on cues of hunger and satiety - Small investment of 8-30 minutes/day Katterman et al., 2016; Kristeller, Wolever & Sheets. 2014
Body Image Recalling Non-judgment Body Image Exercise Handout #4
Building and Holding Hope Share empirical fact of BED treatment: recovery is possible Generalize other achieved goals
Complex Treatment Issues
Binge Eating & Bariatric Surgery - BED predicts outcomes following bariatric surgery - Feelings of loss of control often persist - Problems with symptom measurement lead to reduced ability to detect BED post-surgery - Be aware that BED is a possibility among clients who have undergone bariatric surgery! Chao et al., 2016; Meany, Conceicao, & Mitchell, 2014; Niego et al., 2007; Pekkarinen et al. 2016
Medical Treatments Lisdexamfetamine High risk (80%) of significant adverse effects Topiramate sometimes used off-label Transcranial direct current stimulation Psychosocial treatments are safer and more accessible, particularly in the long-term Davis et al., 2016