Author: Kimberly Crossley, LCSW and Wendy Jensen, LCSW
Center for Change is committed to ongoing research with eating disorders to enhance the awareness and treatment of this population and our clientele. Last year we became part of a research team on Binge Eating Disorder (BED). After reviewing the current literature and in conjunction with our case studies, it was discovered that those with BED have specific treatment needs. There are many commonalities with other eating disorders. However, BED differs from other eating disorders in many ways beyond the lack of compensatory behaviors. It elicits feelings and responses that vary greatly and warrant attention. Our research and gained understanding prompted us to develop several concepts to help us better understand and work with females struggling with BED. Our research of both written materials and case studies are the foundation of this article; we will begin with the following case study with treatment implications.
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 she 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 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 she 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.
Over time, as she was able to discover and express the hurt and anger to her parents because certain foods were being monitored, she gradually found other ways to get 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. All in the family have learned to share feelings and communicate more 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 may have continued to be perpetuated for years and years without resolution.
The characteristics and diagnostic criteria of BED are outlined by the DSM-V. 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:
- 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
- Eating episodes marked by feelings of lack of control
- Often eating when not hungry
- Feelings of guilt, embarrassment, or disgust
- May binge eat alone to hide the behavior
Often, these “adaptive” 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 somewhat different.
An outline derived from “The Obsessive Compulsive Addictive Cycle©” by Michael Berrett, Ph.D., will be used for the framework of explaining the emotional dialogue and compulsive behaviors clients utilize to avoid painful emotions.
- Primary Difficult Emotion ( i.e. 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 out obsession – 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/hopelessness)
- Withdrawal (isolation, secrets, disconnection from self and others)
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 a journal excerpt from a client who suffered with Binge Eating Disorder. 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”. 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 they will acknowledge the DSM criteria for anorexia and bulimia while resisting disclosure about their binge eating behavior, which they feel so much shame about.
Feelings and responses of one struggling with BED are both similar and different from those of other eating disorders. Accordingly, the following interventions help individuals deal with their emotions in order to resolve BED symptoms and behaviors.
- Appropriate assessment according to the DSM-5 criteria including specific items to account for the behaviors and feelings as listed in this article. This may heighten BED anxiety and shame momentarily yet reduces elements that enable the client to harbor shame.
- Medical evaluation and without imminent danger focus on emotional issues while assuring healthy nourishment.
- 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 and associated feelings of shame.
- Self-soothing skills to decrease the intensity of the first three stages of the addictive cycle.
- Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, and Acceptance and Commitment Therapy approaches provide skills to assist the client to manage the underlying psychological 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.
Written: Date unknown
Reviewed and Edited: November 2014