Binge eating disorder (BED) is a newly accepted diagnosis in the DSM-V, the most recent update to the guidebook for mental health. Accordingly, the clinical approach to BED is under increased scrutiny. Treatment using food journals and cognitive behavioral techniques to break the cycle of binges remains the gold standard, but the official diagnosis will generate increased attention and funding to investigate the differences between BED and other eating disorders. It's a relief for clinicians that the committee revising the manual acknowledged the reality and prevalence of BED and put the spotlight on improving care for these patients.
With that controversy in the past, another debate is in the forefront of BED treatment: weight. Patients with anorexia are clearly underweight, whereas those with bulimia range between underweight and normal weight. Treatment of these two illnesses include weight restoration and improved health and nutrition. Binge Eating Disorder is the first eating disorder diagnosis likely to cause weight gain. Eating disorder clinicians, thrust into the obesity debate, are unsure how to respond. The greatest risk is that the overarching societal focus on weight overrides the best clinical approach for these patients.
People with BED are just as focused on feeling overweight as those with other eating disorders and erroneously view weight loss as the solution to all their problems. The problem is that clinicians may agree because these patients usually are overweight and not focus on eating disorder treatment.
The result of weight obsession in BED patients is serial dieting followed by worsening relapses of binging and, ironically, subsequent weight gain. The pattern isn't all that different from all serial dieters except for the two things that make BED an eating disorder: binging rather than overeating in response to dieting, and the internal punishing dialogue, discussed at length in this blog, present in all eating disorders.
In anorexia and bulimia, much of the focus in therapy stems from feeling fat even when normal weight or very underweight. Accordingly, treatment involves challenging the obviously distorted thoughts about body and weight and linking these thoughts with the self-loathing associated with the eating disorder. Countering the distorted thoughts is easier when it's clear the patient isn't overweight at all: the fat thoughts are a distortion, the punishment meted out by the eating disorder.
In a patient with BED, the practical thoughts about being overweight are often true, and the societal focus on obesity reaffirms these same punishing eating disorder thoughts as occur in anorexia and bulimia. It's much harder to convince a patient with BED that the fat thoughts are distortions if the person is overweight. Being overweight, to the sick person, confirms that the person is truly horrific and that weight loss is the only way to recover. This scenario complicates treatment greatly, namely forcing the therapist to confront the thoughts about weight not as a distortion but as a tool the eating disorder uses to worsen the cycle of symptoms.
When weight loss is central to BED therapy, the course of treatment quickly goes awry. The message received by the patient is that weight is the only real problem and the most shameful part of the illness. Immediately, everything else will be secondary, and the punishing thoughts become more true. The practical result inevitably is more hateful feelings that trigger more binging and continued weight gain. Just as in other eating disorders, if weight and body image are taken seriously, rather than as distortions of the disease, treatment won't work. Effective treatment includes normalizing eating with a meal plan while focusing on avoiding triggers for binges and countering the punitive thoughts of the eating disorder.
But any patient with BED will quickly point out the obvious: obesity has serious long term health consequences. No clinician can refute this statement, so it's too easy to find the conversation steered to weight loss as a primary goal of treatment. Unlike any other eating disorder, even drastic measures like Bariatric surgery often enter the discussion. At this point, the underlying emotional and physiological reasons for the binge eating, a core aspect of treatment, are secondary. The eating disorder has hijacked the conversation. As with every quick fix, the scenario will fail and trigger another slip into worsening binging.
Early on, the clinician needs to point out that BED is another eating disorder with the same eating patterns and same punishing thoughts of all eating disorders. Even if BED leads to weight gain, the goal of treatment has to be eating disorder recovery to make any headway. Focusing on weight, which certainly is affected by these illnesses, reaffirms a central tenet of the disorder and always worsens symptoms. When the patient tries to explain the health concerns of being overweight, it's important to acknowledge these statements are true but also to point treatment in a direction that can lead to improvement in the patient's quality of life.
Normalizing eating while stopping binges will lead to weight loss. Addressing the emotional triggers for binges while encouraging compassionate thoughts about oneself are central to effective therapy. To help patients with BED, clinicians need to ignore to obesity epidemic swirling in society and focus instead on what's best for this cohort of patients: treatment for their eating disorder.