after the binge: using the mindful-based strategies to ... strategies to treat binge eating...

After the Binge: Using the Mindful-based Strategies to Treat Binge Eating Disorders

Nancy Romanick, RD, MBA, MAPC, LAC

Objectives

1. Identify the barriers and goals of evidence-based treatment for Binge Eating Disorder and include these in effective treatment planning with clients with BED

2. Identify and implement an effective treatment protocol for clients with BED that include DBT and mindful-based therapy to address the emotional regulation function of BED

3. Use the Mindful Eating Cycle (Am I Hungry? Mindful Eating for Binge Eating Program) to help their clients explore decision-making, including awareness of hunger and satiety, non-restrictive food selection, and mindful enjoyment of food.

BED Newly recognized in DSM5

• Affects 3 million US Adults

• Most common Eating disorder

• More than twice as prevalent as BN/AN combined

• 1.6% women and .8% men

• Median onset 21 years old

• < 50% of adults with BED are obese, 19% are normal weight, 36% are overweight

Diagnostic Criteria - DSM5 A. An episode of binge eating is characterized by:

• Eating an amount of food, in a discrete period of time, that is definitely larger than what most would eat in a similar period of time under similar circumstances

• A sense of lack of control over eating during the episode

• A feeling that one cannot stop eating or control what or how much one is eating

Diagnostic Criteria - DSM5

B. The binge eating episodes are associated with three or more of the following:

– Eating much more rapidly than normal

– Eating until feeling uncomfortably full

– Eating large amounts of food when not feeling physically hungry

– Eating alone because of being embarrassed by how much one is eating

– Feeling disgusted with oneself, depressed or very guilty after overeating

Diagnostic Criteria - DSM5

C. Marked distress regarding binge eating

D. The binge eating occurs on average at least once a week for three months

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behaviors (purging) and does not occur exclusively during the course of anorexia or bulimia

Severity (BE episodes per week):

Mild 1-3, Moderate 4-7, Severe 8-13, Extreme 14 or more

The Challenge of BEDMisunderstood Disorder Co-Morbid Psychiatric Disturbances

Shame and Secrecy Obesity is the focus

Dieting is Problematic Low self-directedness and Perfectionism

Barriers to effective treatment

• Misunderstood disorder

• 30% of individuals seeking professional treatment for weight management have binge eating disorder.

• Often giving the wrong “prescription” of dietary restraint leading to further feelings of failure


• Those with binge eating differ from others seeking weight loss in that they tend to have co-morbid psychiatric disturbances:

–Mood, anxiety, impulsivity, substance use, ADHD and eating pathology.

–Half are depressed or have been depressed.

~ Shapiro 2007, Dingemans 2002, Grilo 2001

Co-occurring Disorders

• High correlation with obesity

• Medical problems: medical problems, PCOS, Diabetes, Cardiovascular disease, gallbladder

• Depression

• Anxiety

• Substance use

• Bipolar disorder and ADHD

Shame and Secrecy

• Binge Eating Disorder goes largely untreated because people who have it don’t readily disclose the behaviors done in private

• Many with BED eat normally around others, or may exhibit restrictive eating and yo-yo dieting.

Focus on Obesity

• Paradoxically, providers who encourage weight management strategies may be unknowingly triggering the symptoms

• Focusing on the obesity, unfortunately perpetuates the shame cycle

• (Sadly, clients don’t understand what they are asking for isn’t working, they just think they are failing treatment over and over again)

• Not all people with BED are obese. It depends on the compensatory behaviors such as excessive exercise or dietary restraint following a binge episode


• Dieting is problematic– Creates feelings of deprivation that leads to

cravings, impulsivity and counter regulation, aggravating binge eating

– Hawks et al 2008

– Creates feelings of shame; more likely to drop out of treatment

– Creates impaired sensitivity to hunger and satiety clues


• Dieting is problematic (cont)

IT’S NOT ABOUT THE FOOD– Binge eating must be the treatment priority

– Abstinence from binge eating is a predictor of successful maintenance and weight loss, which suggests treatment of the eating disorder is the priority over weight loss

~Dingeman 2002, Grilo 2011

• Low self-directedness

– Self-directedness is the ability to regulate and adapt behavior to reach one’s goals

–May explain need to seeking weight loss methods

~Latzer 2003, Dalle-Grave 2012

• Perfectionism triggers binge eating

~Sherry & Hall 2009


• Low interpersonal esteem, interpersonal discrepancies, depressive affect

• Over-valuation of weight and shape

~ Apfeldorfer 2001, Latzer 2003, Sherry & Hall 2009, Dalle-Grave 2012


• Cessation of binge eating

• Improvement in eating-related psychopathology

• Reduction in psychiatric co-morbidity

• Improvement in physical health and relationship with the body.

Goals for Treatment of BED

• Treatment follows function

• The key to determine effective treatment is based largely on the function of the binge eating.

• The Why? Behind the Eating disorder will guide finding a replacement for the need it is replacing.

Cessation of the Binge Eating

• Treatment follows function (Cont)

• Binge eating may be a valuable tool in helping someone protect themselves from harm, rejection, failure, power or other threatening situations. This is supported by a strong belief system.

• An unconscious decision occurs when faced with the choice to do it differently.


• OF COURSE!• The behavior is reasonable and

understandable given the needs and life circumstances.

• “I’ve never met anyone who didn’t have a great reason for having an eating disorder.”

~Kari Anderson DBH, LPC


• Abstinence from binge eating is a predictor of successful maintenance and weight loss, which suggests treatment of the eating disorder is the priority over weight loss.

~Dingemans 2002, Grilo 2011

• Significantly greater BMI reduction (3.5 - 4.3%) compared to those who continue to binge eat.


• Eating-Related Psychopathology

– Perfectionism

– Intolerance to ambiguity

– Unable to trust themselves

– Inability to accept self, weight and shape

– Inability to recognize the underlying beliefs


• Where to start-

– Help the client identify the many faces protecting the function of the eating disorder.

– Calm and reassure by developing the voice of self compassion, “of course” to create a safe environment for change.

– Start with validating the need for the eating disorder thus far.


“Some individuals respond to emotions by eating. Food and the eating process serve to comfort, distract or “distance” oneself from emotions…[this] interferes with the body’s natural physical cues of hunger, fullness, appetite and satiety…the result is disconnection from internal cues.”

~Moving Away From Diets Kratina, King, and Hayes


• Problems with emotions

– Difficulty recognizing, labeling and self-regulating emotions

– Predominant emotions before a binge: anger, loneliness, disgust, exhaustion, shame

– Lack of coping skills

– Difficulty listening to their body and providing self-care


Dissociation and Distraction

Bingeing becomes a Trance-like state:

– To escape emotions which are intolerable and seen as pathological

– To escape thinking about the long-term consequences of actions or to procrastinate unpleasant activities

– To escape one’s critical thoughts and feelings of inferiority

~Shafran 2001, Leahy 2002, LaMella 2010


• Traditional CBT is the most widely researched method of treatment with BN and BED.

• CBT has been shown to eliminate binge eating in 50% participating in treatment. ~ Wilfley, Wilson & Agras 2010

• Traditional CBT alone doesn’t address the internal blocks and motivational factors necessary to change behavior long term

Evidenced Based Treatment of BED

• Dialectical Behavior Therapy– Considered a form of CBT

– Dialectics (acceptance and change)

– Seemingly opposite stances can both be true at the same time. Therefore one can be deemed completely acceptable and at the same time need to change.

– Key to dialectics is the balancing act between validation and pushing for behavior change

– Moving out of black and white, extreme thinking, into a both/and approach (middle path)

Linehan, 1983, Telch 2001


• Dialectical Behavior Therapy (cont)

– Considered a mood regulation model for the treatment of binge eating

Linehan, 1983, Telch 2001

– Mindfulness is taught to counteract dissociation

– Rapid response of binge abstinence, continues throughout treatment an a one year follow up with DBT

– Safer and Joyce 2011


• Dialectical Behavior Therapy (cont)– Basic CBT eliminated binge eating and purging in about

50% participants…but when mindfulness training and acceptance-related procedures have been adapted and introduced to eating disorder treatment we have seen the elimination of bingeing sustained over time.

– ~ Safer & Joyce 2011, Anderson & May 2013


Mindfulness

The ability to be aware of your thoughts, emotions, physical sensations, and actions in the present moment without judging or criticizing yourself or your experience.

~ Jon Kabat-Zinn

• Mindfulness-based approaches provide individuals with a heightened ability to simply observe feelings and experiences and disengage automatic reactivity.

• It cultivates a wiser and more balanced relationship with their selves, their eating, and their bodies.

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AM I HUNGRY- ME-BE

• Key treatment components:

– Why do I eat? Eating Cycles (Mindful, Binge, Restrictive, Overeating)

– Pendulum Swing (Finding the Middle Path)

– Dichotomous thinking

– Body Wisdom – Hunger fullness awareness

– It’s not about the food – meeting your true need

– Internal dialogue – Self care voice (Validation and Change)

From Eat What You Love,

Love What You Eat for

Binge Eating

By Michelle May, MD and

Kari Anderson DBH LPC

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AM I HUNGRY- ME-BE

• Key treatment components:

– Reducing triggers (TFAR)

– Mindfulness Based Stress Reduction techniques

– Awareness Journals

– My Goodbye!

– Emotions and Needs

– Balancing eating and nourishment- Eat What you love!

– Fearless eating


Love What You Eat for Binge

Eating



Mindful Eating Cycle

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Eating



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Mindful Eating Cycle

Instinctive Eating Cycle

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Eating




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Eating




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Eating




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Eating




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Eating




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Eating




Binge Eating Cycle

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Eating



Binge Eating Cycle

Replacement for unmet needs

Escape from awareness of self-critical thoughts and negative emotional states

Cycle drivers for binge eating

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Eating



Binge Eating Cycle

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Eating



Binge Eating Cycle

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Eating



Binge Eating Cycle

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Eating



Binge Eating Cycle

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Eating



Binge Eating Cycle

Restrictive Eating Cycle

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Eating




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Eating




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Eating




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Eating




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Eating




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Eating




Trigger React

Re-Act

Mindlessness

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Trigger Pause

Respond (Response-Ability)

Mindfulness

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BED Research Study 2012

• Purpose was to test a 10 week program for BED using evidence based modalities for BED integrating the Mindful Eating Cycle Framework

• Research by Michelle May, MD and Kari Anderson DBH LPC

BED Research Study 2012

Six measures pre and post

• BES : Binge Eating Scale

• MAAS: Mindful Attention Awareness Scale

• STC : Starting the Conversation

• RAPA: Rapid Assessment of Physical Activity

• PHQ -9 Patient Health Questionnaire

• GAD-7 General Anxiety Disorder

Results Summary Study 2012• Participants started at severe binge eating level; BES

decreased to non-bingeing level by 10 weeks

• Decrease depression – moderate to mild

• Decrease anxiety- High mild to low mild

• Improved Mindful Awareness/Attention

• Improved dietary choices

• Slight improvement in physical activity

• Low attrition rate (14%)

• High participant evaluation score (9.6 out of 10)

Role of Eating Cycle Awareness

• Binge Eating = Out of Control

• Restrictive Eating= In Control

• Mindful Eating = In Charge

Autonomous Eating

– More concern for the quality of one’s food

– More energy, sustained healthy eating

Control Eating

– Drains energy and more concerned for quantity of food

Verstuyf, Patrick, Vansteenkiste & Texeira, 2012

Motivation and Eating

66

Intrinsic goals that are autonomous in motivation have distinctly better outcomes in eating regulation than those with extrinsic motivation and controls.

Pelletier and Dion 2007

Better Outcomes

67

Mindfulness-based approaches provide individuals with a heightened ability to simply observe feelings and experiences and disengage automatic reactivity.

Cultivates a wiser and more balanced relationship with their self, their eating, and their body.

Conclusion

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Contact Information

Nancy Romanick RDN, MBA, LAChttp://www.mybalancedlifecounseling.com/my_Balanced_Life,_LLC/Welcome.html

For information on training www.AmIHungry.com

email information:

[email protected]

References will be provided

http://www.mybalancedlifecounseling.com/my_Balanced_Life,_LLC/Welcome.html

http://www.amihungry.com/

mailto:[email protected]

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