Wednesday, January 06, 2010

Psychological Treatments of Binge Eating Disorder (Research Review)

The Archive of General Psychiatry recently posted the following article, which I want to talk about a little bit since binge eating disorder (BED) is something about which I have some strong opinions.
Psychological Treatments of Binge Eating Disorder

G. Terence Wilson, PhD; Denise E. Wilfley, PhD; W. Stewart Agras, MD; Susan W. Bryson, MA, MS

Arch Gen Psychiatry. 2010;67(1):94-101.

Context Interpersonal psychotherapy (IPT) is an effective specialty treatment for binge eating disorder (BED). Behavioral weight loss treatment (BWL) and guided self-help based on cognitive behavior therapy (CBTgsh) have both resulted in short-term reductions in binge eating in obese patients with BED.

Objective To test whether patients with BED require specialty therapy beyond BWL and whether IPT is more effective than either BWL or CBTgsh in patients with a high negative affect during a 2-year follow-up.

Design Randomized, active control efficacy trial.

Setting University outpatient clinics.

Participants Two hundred five women and men with a body mass index between 27 and 45 who met DSM-IV criteria for BED.

Intervention Twenty sessions of IPT or BWL or 10 sessions of CBTgsh during 6 months.

Main Outcome Measures Binge eating assessed by the Eating Disorder Examination.

Results At 2-year follow-up, both IPT and CBTgsh resulted in greater remission from binge eating than BWL (P < .05; odds ratios: BWL vs CBTgsh, 2.3; BWL vs IPT, 2.6; and CBTgsh vs IPT, 1.2). Self-esteem (P < .05) and global Eating Disorder Examination (P < .05) scores were moderators of treatment outcome. The odds ratios for low and high global Eating Disorder Examination scores were 2.8 for BWL, 2.9 for CBTgsh, and 0.73 for IPT; for self-esteem, they were 2.4 for BWL, 1.9 for CBTgsh, and 0.9 for IPT.

Conclusions Interpersonal psychotherapy and CBTgsh are significantly more effective than BWL in eliminating binge eating after 2 years. Guided self-help based on cognitive behavior therapy is a first-line treatment option for most patients with BED, with IPT (or full cognitive behavior therapy) used for patients with low self-esteem and high eating disorder psychopathology.

Trial Registration Identifier: NCT00060762

Author Affiliations: Rutgers, The State University of New Jersey, Piscataway (Dr Wilson); Washington University School of Medicine in St Louis, St Louis, Missouri (Dr Wilfley); and Stanford University School of Medicine, Stanford, California (Dr Agras and Ms Bryson).

Binge eating disorder (BDE) was added the DSM-IV as a new (and provisional) diagnosis in 1994. Since then, as the article points out, the diagnosis has shown itself to be a reliable and valid diagnosis.

From the introduction:
Binge eating disorder is characterized by frequent and persistent episodes of binge eating accompanied by feelings of loss of control and marked distress in the absence of regular compensatory behaviors. The disorder is associated with specific eating disorder psychopathology (eg, dysfunctional body shape and weight concerns),4 psychiatric comorbidity, and significant health and psychosocial impairments.5 Binge eating disorder is also linked with overweight and obesity.6
In general, as with most diagnoses, cognitive behavioral therapy (CBT) is the most widely used therapeutic approach, and the most tested. In this study they used CBT with a "guided self help" twist on the model, alongside behavioral weight loss approaches (BWL - this is what you might get from a nutritionist, focusing on nutrition, calorie restriction, and exercise), and interpersonal psychotherapy (IPT), which like CBT is a "reliably effective in eliminating binge eating and reducing associated psychopathology in the short- and longer-term."

Here is how they define the IPT model they used:

Interpersonal psychotherapy for BED was formulated by Wilfley.7, 26 It was based on the treatment developed by Klerman et al27 for depression, and Fairburn28 later adapted it for the treatment of bulimia nervosa. The treatment is manualized. The first phase is composed of 4 sessions and is devoted to a detailed analysis of the interpersonal context within which the eating disorder developed and was maintained. This leads to a formulation of the current interpersonal problem areas, which then form the focus of the second stage of therapy aimed at helping the patient make interpersonal changes in the specific area or areas identified. The last 3 sessions are devoted to a review of the patient's progress and an exploration of ways to handle future interpersonal difficulties. Although links are made throughout treatment between interpersonal events and binge eating, the therapy does not contain any of the specific behavioral or cognitive procedures that characterize CBT. In the current study, all sessions were individual and 50 to 60 minutes long except for the first, which was 2 hours long. The first 3 sessions were scheduled during the first 2 weeks and were followed by 12 weekly sessions and the final 4 sessions at 2-week intervals, for a total of 19 sessions during 24 weeks. The total therapy time was the same as that for BWL.

The CBTgsh model they used is described here:
This intervention is derived from manual-based CBT. The primary focus is developing a regular pattern of moderate eating using self-monitoring, self-control strategies, and problem-solving. Relapse prevention is emphasized to promote maintenance of behavioral change. The principal role of the therapist is to explain the rationale for the use of the self-help manual, generate a reasonable expectancy for a successful outcome, and to motivate the patient to focus on using the manual. There were 10 treatment sessions, each lasting approximately 25 minutes, except for the first session, which was 60 minutes long. The first 4 sessions were weekly, the next 2 occurred at 2-week intervals, and the last 4 occurred at 4-week intervals. The therapists were first- or second-year graduate students with no experience in CBTgsh or treating BED, 4 at Rutgers University and 4 at Washington University. Dr Fairburn conducted initial training in CBTgsh in a 3-hour workshop. The therapists did not receive regularly scheduled supervision. As with the other 2 treatments, quarterly meetings across sites were held throughout the study.
This is an interesting study and it proves that a psychotherapy approach is superior to behavior modification in controlling binge eating behavior. In the comment section of the paper they discuss the outcome:
Consistent with some previous studies,11, 13 ours found no difference among the 3 interventions at posttreatment on binge eating; specific eating disorder psychopathology of body weight, shape, and eating concern; or general psychopathology. At the 2-year follow-up, however, both IPT and CBTgsh were significantly more effective than BWL in eliminating binge eating. This superiority of a specialty therapy over BWL for BED is supported by 2 recent short-term studies. Munsch et al36 found that CBT was significantly superior to BWL, and Grilo and Masheb17 showed that a self-help version of CBT was significantly more effective than self-help BWL. Devlin et al,37-38 in a randomized double-blind placebo-controlled study, found that the addition of CBT—but not antidepressant medication—to BWL treatment significantly enhanced outcomes at posttreatment and 24-month follow-up. Interpersonal psychotherapy was also more successful in retaining patients in the trial than BWL or CBTgsh. Our dropout rate for BWL was consistent with previous research.36, 39 The CBTgsh attrition in our study was greater than in others (eg, Grilo and Masheb17) possibly because it was contrasted with longer, more "face valid" treatments. This might also explain the difference in suitability ratings.
It's good that they compared the three approaches, although the IPT and GBTgsh approaches were not different enough to me to generate significant differences in results. As someone who works with clients on binge eating behaviors, this study proves to me that many of my clients need therapeutic intervention in order to overcome this behavior issue - BWL efforts are not nearly enough.

However, I would recommend a completely different approach. It seems there was very little effort to look at the etiology of the binge behavior in autobiographical details. In general, I think this is necessary, while also acknowledging that the current managed care situation requires very short-term therapeutic approaches such as the ones used in this study.

My sense is that binge behavior is a symptom of pervasive but low-grade depression, dysthymia, often with an early onset (APA, p. 380-381), meaning that the behavior begins in the teen years. Many clients may also exhibit more severe depression, anxiety, or other psychological issues, as well as having experienced childhood trauma, neglect, or abuse.

There has been very little research into the connections between binge-eating disorders (BED) and dysthymia, although Kristin Moerk has conducted a preliminary study that deserves follow-up (Moerk, 2002). She offers the following summary of her dissertation:

Many of the personality traits selected as candidate potentially relating to high comorbidity between BED and depression were linked only to depression and not observed at higher level in the pure BED group than in the control group. These traits included: perfectionism, low self esteem, sociotropy, autonomy, dependency, and self criticism. (Moerk, 2002, p. 7)

These findings are consistent with my sense that binging clients exhibit low self-concept, perfectionism, and self criticism. The Moerk study included dysthymics in the depressed group, so her research can be extended to include this population as well as those more severely depressed. Other researchers have found that dysthymia was more strongly correlated with binge eating and bulimia than major depression (Geist, Davis, & Heinmaa, 1998; Perez, Joiner, & Lewinsohn, 2004).

Dysthymia seems to respond best to a combination of anti-depressants and therapy (Grohol, 2008), with cognitive behavioral therapy (CBT) being the most widely studied psychotherapy approach for this disorder. The study presented above is notable in that there was not a drug group, as is generally the case. I was glad to see that they were willing to avoid the money that comes from drug companies to fund such research.

My bias would be to use Richard Schwartz’s Internal Family Systems Therapy (IFS), which was developed during work with survivors of child abuse and has proven successful with bulimics and anorexics, as well as less challenging clients—he includes a whole chapter detailing his work with a bulimic client in his book (Schwartz, 1995, p. 61-83). Essentially, IFS is a form of parts work, not dissimilar to Ego States work (Watkins & Watkins, 1997) or the Voice Dialogue model (Stone & Stone, 1989).

Using the IFS model, the binging behavior is not seen as the primary issue, but rather as a coping mechanism (what IFS terms “firefighter” behavior in that the binging “part” responds to pain by trying to “put out the fire” through addictive behaviors). In employing the IFS model, the client becomes aware that the behaviors—the parts, schemas, ego states, or subpersonalities—are not who she is as a person but, rather, are merely wounded parts that need to be “unburdened.”

Therapy begins with an exploration of the most dominant parts, often that would include the “Perfectionist” and the “Inner Critic,” parts that are known as “managers” because their role is to keep the self-system functional by pushing out negative feelings, such as depression. The “firefighters” (or binging behaviors) are activated when the managers fail to keep the “exiled” feelings or “parts” out of consciousness. The exiles are the wounded parts that carry the burden of dark emotions, such as sadness and depression (or more significantly, trauma, abuse, and neglect), that the managers are afraid will take over the self-system if they are not exiled.

Therapy consists of systematically negotiating with managers and firefighters to uncover and unburden the exiles. Once the exiles and other parts are unburdened, they typically adopt new and more functional roles in the self-system (Schwartz, p.53).

Finally, the client learns to differentiate her parts from the inner core of Self—also known as Atman, Buddha-nature, Soul, and so on—so that she can learn to become Self-led (Schwartz, 41). When the client can become Self-led, individual parts, even if they are not fully unburdened, no longer are as capable of hijacking the self-system. Developing access to the Self can be an invaluable tool in coping with both the dysthymia (or depression, anxiety, trauma, and so on) and the binge behavior.

It is worth noting that Schwartz also advocates working to create some contact with the Self very early in therapy so that is can act as a co-therapist in the process. In his model, much of the healing comes from the client's Self doing internal attachment work with the wounded and burdened parts (Harryman, in press).

I would really like to see someone put this model up against CBT and pharmaceuticals. I think it will prove superior.


American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: Author.

Geist, R., Davis, R., & Heinmaa, M. (1998). Binge/purge symptoms and comorbidity in adolescents with eating disorders. Canadian Journal of Psychiatry, 43, 507–512.

Grohol, J. M. (2008). Dysthymia treatment. Retrieved November 28, 2009, from

Moerk, K. C. (2002). Personality in binge eating disorder and depression: Do similarities in personality traits partially account for comorbidity findings?. Unpublished doctoral dissertation, State University of New York at Stony Brook, New York.

Perez, M., Joiner, T. E., & Lewinsohn, P. M. (2004). Is major depressive disorder or dysthymia more strongly associated with bulimia nervosa?. International Journal of Eating Disorders, 36(1), 55 - 61.

Schwartz, R. (1995). Internal family systems therapy. New York: Guilford Press.

Stone, H., & Stone, S. (1985/1989). Embracing our selves. Novato, CA: New World Library.

Watkins, J. G., & Watkins, H. H. (1997). Ego states: Theory and therapy. New York: W. W. Norton & Co.

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