Eating Disorders

Therapy Insights in Treating Binge Eating Disorder

One patient dealing with abuse and trauma issues in therapy used binge eating to relieve the symptoms of depression and anxiety. As work in therapy continued, it was discovered that this patient began emotionally eating at the same time the abuse occurred. As a child certain foods were monitored by her parents, such as cereals with sugar. She was only allowed such cereals one day out of the week. Therefore, the intake of cereal on days other than the one already designated and / or if she ate more than a certain amount was monitored. As this patient got older, she learned that much focus and attention was given to what kind of food she ate or did not eat.

When she was unable or unwilling to verbalize her emotions and feelings, she turned to binge-eating behaviors. It became a source of contention between the patient and her parents. In treatment it was discovered that food was being used as a source of getting attention, although negative in nature, from her parents. Her parents did not know she was being abused and, as a child, she was threatened by the perpetrator if she told anyone about what was happening. As she got older, when she and her parents did not agree about something, she turned to food as a retaliation against them.

However, as she was able to discover and express the hurt and anger to her parents because certain foods were being monitored, she gradually used other means of having her needs met. No longer did she need to "rebel" or retaliate with food. Instead, she was able to verbalize the emotions and feelings, and as she did so, the binge eating behaviors subsided. Work was done with the parents to help them deal with their emotions about the abuse as well. They felt helpless and expressed failure for not doing something about the abuse. However, they did not know it was taking place. Now they communicate their feelings and opinions openly.

This case study shows the importance of addressing the psychological issues at the same time as teaching healthy nutritional philosophies and practices. If only body image and eating patterns were emphasized, the destructive cycle of binge eating would continue to be perpetuated for years and years without resolution.

The characteristics and diagnostic criteria of BED are outlined by the DSM-IV. Many patients struggling with BED are ashamed about what they are doing and fear others finding out. As a result, it is helpful to know some of the indicators of the disorder.

The warning signs of BED are many:

– Rapid weight gain or obesity
– Constant weight fluctuations
– Frequently eating abnormal amounts of food in a short period of time, usually less than two hours
– Not using any methods to purge foods
– Eating rapidly, often swallowing without chewing
– Feeling a lack of control over one's eating
– Eating alone
– Secretive eating habits
– Hiding or hoarding food, often high calorie / "junk" food
– Eating late at night
– Eating large amounts of food without being hungry
– Disgust and shame with self after overeating
– Coping with emotional and / or psychological states such as stress, unhappiness, or disappointment by eating
– Consuming foods to the point of being uncomfortable or even in pain
– Attributing one's successes and failures to weight
– Avoiding social situations, especially those involving food

Generally, these warning-sign behaviors are used to comfort and soothe the individual. They are not necessarily used as punishment. Accordingly, there are different rewards and struggles for the individual than the rewards and struggles of one struggling with anorexia nervosa or bulimia nervosa. The cycle of addiction is also different.

Primary Difficult Emotion (ie anger, hurt, sadness, loneliness, etc.)
Obsessive Thoughts (distracting thoughts or obsessing about the compulsive behaviors)
Anxiety (builds from ruminating thoughts and anticipation)
Compulsive Behaviors (acting on addiction – eating disorder behaviors, drugs / alcohol, sex, etc.)
Relief (oft described as "high", "euphoria" – temporary in nature due to cessation of anxiety)
Secondary Difficult Emotions (guilt / shame)
Withdrawal (isolation, secrets, etc.)

For anorexia nervosa and bulimia nervosa the addictive cycle flows in the manner listed above. However, with binge eaters the "relief" stage of the cycle precedes / accompanies the compulsive behavior of binging. Then they move directly into the stage of "secondary difficult emotions" and experience what seems to be a more intensive self-loathing due to unhealthy cultural norms about over eating without compensatory behaviors.

The following is journal excerpt from a client whose diagnosis was BED, with a prior diagnosis of anorexia. Watch for the placement of the "Relief" phase of the addictive cycle in both entries:

How I feel after I restrict:

I feel like I'm beating the monster. I'm rebelling against it. But I feel the emptiness within me. Maybe I'm meant to feel the missing hole. But if this is what not getting what I want is, then what's the point? I may be beating the monster, but yearning can grow to a great catastrophe later. This could be the "right" thing though. I don't feel embarrassed, like a pig around others. But my mind is constantly thinking of new things I'm missing out on. I'll feel lighter though, a spring in my step. No bloating or excess. Even better, I might like what my body will look like.

How I feel after I binge:

Initially I feel relief. I've come to my comfortable and safe place. I feel a numb high come over me. This familiar action of taking food and putting it in my mouth. This is what I know how to do, something I'm good at. I feel invisible. Nothing can come between the food and me. The world around me is on a pause for me. Reality falls on me and slams me on the stone floor. I feel a deep pain in the pit of my stomach or guilt, regret, hopelessness. I hate my body. I feel injected with poison, tainted. This body is not mine, I won't accept that. This body is ugly, it belongs to a weak clumsy owner. What have I become and you know what, you're even more meaningless because you don't even purge. Too chicken. Everybody else assumes you do. Perhaps I can keep the food to learn my lesson. Let it grow like layers of gunk within me.

The entry from the binge episode identifies the modified addictive cycle as previously explained, wherein "relief" accompanies the "compulsive behavior" instead of coming after the addictive behavior. When a client struggles with binge eating they exhibit different types of emotions in both blatant and subtle ways. Oft times these patients, if they have a history of anorexia or bulimia, will acknowledge the DSM criteria without disclosing the "warning signs" due to intense shame.

Feelings and responses of one struggling with BED differ from those of other eating disorders. Accordingly, the following interventions and implications help individuals deal with their emotions in order to resolve BED symptoms and behaviors.

Appropriate assessment according to the DSM-IV criteria including specific items to account for the "warning signs" as listed in this article. This may heighten anxiety and shame momentarily yet reduces elements that enable the client to harbor shame.

Medical evaluation and without imminent danger focus on feelings instead of weight and dieting.

Dieting history, focusing on intense craving, out of control feelings with food and the rapid and unconscious eating that "dieting mentality" evokes. Often these are precursors for binging diagnosis and feelings of shame are associated.

Self-soothing skills to decrease the intensity of the first three stages of the addictive cycle as well as provide more permanent measures they gain in the "relief" phase.

Cognitive Behavioral Therapy and Dialectical Behavioral Therapy approaches provide skills to assist the client to manage the essential implications implications of BED.

We advocate that clinicians, dietitians, and direct-care staff who work with eating disorder patients become aware of the unique differences clients with BED experience so they can be better supported away from shame and into recovery.

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