BED7787 - SECTION 5: THE TREATMENT PROCESS
Overview of the Components of Treatment
As we have previously noted, there are two potential roles that the clinicians taking this course may have when working with a patient with BED. One role may involve serving as the provider of an initial assessment, followed by a referral of the eating disordered patient to a specialist in the treatment of BED. A successful referral, or transfer of care, to either a specialist in BED or to a BED program will require that the referring clinician have some knowledge about the treatment program and services that will likely be offered to the patient.
The other role would involve the use of best practices approaches as part of an overall strategy to address the BED as it manifests itself in the patient. It is understood that in such instances, the BED would likely not be the only issue addressed with the patient. The clinician would likely also be addressing some combination of depression, anxiety, impulse control and self-esteem problems, as well as a number of health issues that frequently operate co-morbidly with the BED.
We will therefore begin to inform the clinician on this arena with a general overview of services that the eating disordered patient can likely expect as a part of an overall treatment plan. We will then go into some more detail on various aspects of this overall treatment plan. As we have noted, treatment with the eating disordered patient will generally include a number of different components, such as:
1) Individual therapy
2) Family therapy and/or contact/education
3) Group therapy and/or peer support
4) Nutritional/dietary counseling
5) Medication and medication management
If the patient's weight has reached a point where it is potentially threatening to the patient's life or health, treatment may include some additional and more intrusive components:
6) Medical supervision
7) Closely supervised caloric / food management
Patients with co-morbid disorders may also receive additional services to target those problems:
8) 12-step support for substance abuse problems
9) Other supportive services as needed
10) Self-help materials, based upon CBT principles
The first steps in a therapeutic change process will involve identifying a problem (including having the patient acknowledge the problem), developing goals for change, and building motivation to engage in the actions to bring about those desired goals.
If the patient is not willing to take the first steps – if he or she is not willing to even acknowledge the presence of a problem - then motivation for treatment is very difficult to develop. Therefore, the appropriate role of the clinician at that point in time includes bringing to bear the knowledge and skills to move through that point of initial resistance.
If it is felt that the resistance to change is primarily attributable to the BED – and the clinician has limited background and skills in addressing BED - then it may make more sense for the assessing clinician to refer the patient more quickly to an eating disorders specialist.
35% of "normal dieters" progress to pathological dieting.
Source: National Eating Disorders Association (Citing Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18 (3))
Decisions about what components of treatment to include will be based upon factors such as the patient's pathology, body weight, health and motivation for treatment. The decision to involve family or other adjunctive parties will be determined by whether such activities are seen as supportive or destructive to overall treatment.
Please be aware that most BED specialists today use a combination of approaches, predominately based upon the approaches used in BN and with obesity. Because families represent a vital part of the support system for eating disordered patients – particularly pre-adolescents and adolescents – family therapy is frequently some component of the overall treatment approach. With adults who suffer from BED, treatment may also include couples counseling.
Before we look at the different models that are generally used to treat eating disorders, it may be helpful to reiterate the general clinical landscape of the "typical" BED patient. This will help make connections to why certain approaches may be helpful, and will inform the larger shape of the treatment plan for BED.
As we have noted, there is a great deal of correlation between BED and depression and anxiety. Eating, for patients with BED, appears to be frequently related to affective distress. Given what appears to be a fairly complex relationship between mood and anxiety disorders and binge eating behaviors in BED, the treatment plan will usually need to include approaches that target depression and anxiety, and help patients to increase awareness of their affective states. This will usually include cognitive techniques, skill building and education for improving affective skill sets, and helping the patient to examine and make alterations in their external support system.
Patients with BED also frequently exhibit deficits with and disorders of impulse control. This means that some focus should be placed upon skill building in terms of impulse control and emotional self-regulation. 12-step support groups and sponsors may work with some patients.
Additionally, relapse prevention approaches to bingeing behaviors are useful in terms of helping to prevent or minimize the frequency, duration and intensity of binges. Additionally, clinicians should assess the level of the patient's overall interpersonal effectiveness skills, since these skill sets can often be affected by both the precedents of and the consequences of BED, including the social isolation that can accompany obesity.
As we have previously noted, some research has shown that BED patients also have a higher incidence of a history of abuse – emotional, physical, and perhaps sexual – than the population at large. This can affect the patient's development in a number of important ways, and leave residual elements of Post-traumatic Stress Disorder. While CBT is an important component of responding to an abusive history and its sequelae, there are a number of other approaches for survivors of different kinds of abuse that may also be useful in treating this aspect of BED, when appropriate.
Low self-esteem is very common in BED patients, and cognitive restructuring of self-image, skill building for more successful interactions, and a great deal of positive emotional support will always be an important part of the treatment plan.
Finally, patients with BED typically present with a preoccupation with body size, weight – and with eating. Thought stopping and thought redirection skills are among the usual cognitive approaches to preventing ruminative thoughts about weight and eating. Additionally, dialogue and re-education about ideal body size and cultural values about thinness will likely be an important part of the treatment plan for certain patients with BED.
With this larger perspective on the overall treatment plan in place, this course will now turn to some of the more common approaches to addressing the core behaviors of BED.
The Psychodynamic Model
A psychodynamic understanding of BED understands the problems primarily as signs and symptoms of internal turmoil and conflicts. The roots of this approach go back in time to the early days of psychoanalysis and the work of Sigmund Freud. However, Freud's original conceptualization has of course evolved, as later research and newer schools of thinking have modified some of the key principles from his original theories.
Psychodynamic understandings of BED today, like traditional psychoanalysis in the past, emphasize that symptoms are expressions of inner conflict. Modern psychoanalysis, however, does not see instinctual life as the predominant driving force in human conflicts.
Unconsciously, eating could become a forbidden action or an overly satisfying action. When it is performed it becomes either a binge, or a total avoidance of food, depending on the disorder and what the patient is expressing though it.
A modern psychodynamic understanding of BED includes the role of gender, society and context. The therapeutic work, however, still lies in the uncovering and reconfiguring of the unconscious thoughts and conflicts with regard to the eating disorder. However, not many clinicians use a psychodynamic model alone. Many may use an understanding of the issues from a dynamic perspective while they use other techniques to help the patient.
If one operates within the conceptual framework provided by the masking theory of BED, some of the clinical interventions would be psychodynamic in nature. This would include unlocking the conflicts that cause the patient to attribute their problems to their BED and – through insight oriented interventions – reshape their understanding of the problems.
Cognitive Behavioral Model
The cognitive behavioral model emphasizes changing the eating disordered behavior through addressing the thought patterns that underlie both the uncomfortable feeling states of the patient and the maladaptive behaviors. A pure cognitive model is not interested in the unconscious meaning of eating, body, or self. It is interested in changes in thinking – which leads to changes in affect – and changes in behaviors in ways that reinforce better thinking and feeling.
According to this model, attitudes about food and body image are changed by addressing the cognitions that prompt the disordered thoughts, unhealthy feelings, and choices of behaviors. This model is frequently used with BED patients in an attempt to help them establish a healthier relationship with food. According to many researchers, CBT is the treatment of choice for BED. (29)
The following are some of the cognitive distortions addressed by cognitive behavioral therapy:
Dichotomous thinking (black and white thinking): i.e., if I eat one cookie or one slice of pizza, I can binge because I ruined the whole day.
Personalization: i.e., they are all looking at me because I am flabby and fat and out of shape.
Catastrophysing: i.e., if I lose control one time, I am a loser and an out of control person.
Magnification: i.e., when I cannot eat exactly what have planned for a meal, my life is ruined.
Arbitrary Inference: i.e., people who are thin get the nice boyfriends so I might not even try since I am so fat.
Overgeneralization: i.e., If I don’t eat healthy I will get cancer like uncle x who ate a lot of fat in his diet. However, I am so fat I do not even care anymore.
Superstitious Thinking: i.e., I am so fat that I will get cancer anyway (die young or fill the blank.
In this model, the clinician helps the patient by reframing his/her thoughts. The patient learns how to approach food in a calm and prescribed manner. The patient learns how to talk him/herself out of thoughts that set him/her up to eat in an unhealthy manner either before eating, or while he/she is in the middle of a binge or restraining.
Cognitive therapy has proved to be very efficient with bulimic individuals, especially during the beginning of treatment. It helps individuals stop the binge and purge cycle faster than other models. Therefore, it is likely to be effective with the binge components of BED.
In the real world, CBT is not the only element of a comprehensive approach. A more comprehensive approach combines elements of cognitive behavioral therapy with interpersonal skill building, increasing tolerance for distress, and targeted work on the development of better emotional self-regulation, incorporating the use of a technique called "mindfulness". Mindfulness is a gentle and supportive approach for learning how to remain in the present – even when that present is painful due to intense emotional material - and is helpful to people with emotional dysregulation in terms of minimizing defensiveness and maximizing a sense of self-efficacy.
Disease Addiction Model
This model has been in place for Alcoholics since the 1920s. Overeaters Anonymous uses the same principles as Alcoholics Anonymous, including the use of a 12-step approach. Overeaters Anonymous helps people with BED deal with their compulsivity with food by helping them gain control. Additionally, many treatment programs that offered inpatient and intensive outpatient substance abuse services extended their approaches to patients with AN and BN.
For patients with BED, this model views the feelings associated with the eating process as the addiction, and asks people to stay away from particular foods that are believed to be triggers to this addictive feeling process. According to this model, addictive foods include foods that are high in fat, sugar and carbohydrates. In this model, people with BED are seen as recovering but never fully recovered.
For other patients suffering from eating disorders, this approach focuses on the changes in brain chemistry experienced by the eating disordered patient as they withhold food. Some studies suggest that brain chemistry associated with eating – through endogenous opioid receptors - approximates the chemistry seen with the use of addictive substances. Recovery, the theory goes, would then be created through the application of principles used in substance abuse recovery.
Based upon this theory, researchers have been experimenting with the use of Naltrexone – an alcohol and heroin anti-craving medication that works on the opioid receptor sites in the brain – to address certain of the eating disorders. Some research does suggest that Naltrexone may decrease bingeing and reduce purging in patients with BN, as well as in patients with a bingeing subtype of AN (51). Because these experiments are still early in the process, it is not possible to determine whether Naltrexone will have a positive role to play in addressing BED.
Standing alone, this specific model does not deal with the underlying issues that drive people to their compulsive behaviors because it views those behaviors as addictive and uses the 12-step model of support to prevent these maladaptive behaviors.
Overall, the trend appears to be moving away from a primary reliance on models of addiction to treat eating disorders. Outcome studies have been less favorable to this mode of treatment, and the theoretical underpinnings for using this model are unproven and much called into question.
However, many professionals believe that this approach does hold some useful components that can be incorporated into an overall treatment strategy. In 12-step programs, other people with similar problems – but who are more advanced in their recovery - are available to provide support to those who feel symptomatic at any time of the day or the night. This support reduces social isolation and impedes the ability of the patient to engage in distorted thinking about their eating approaches.
There are other components of the addiction model that may have some applicability to work with eating disordered patients. A relapse prevention plan, for instance, is a useful tool for BED patients. This tool helps a patient to examine and prepare for events and "triggers" that lead to therapeutic regression. This tool will typically incorporate psychodynamic, cognitive and solution focused approaches as it attempts to provide a supportive structure for the change process.
The use of the relapse prevention plan engages the patient in identifying the events or "triggers" that might lead to episodes of bingeing or food restriction. These might be external events, or they might be internal challenges. The patient is encouraged to work with the clinician to develop short-term and long-term solutions that will allow the patient to prevent the triggers from setting off unhealthy behavioral choices.
In the process of working on a relapse prevention plan, the clinician is helping to empower the patient by having the patient name their triggers, understand how their triggers work, and find solutions that protect them from their triggers. There are aspects of this that strongly support the cognitive and behavioral work that is a strong component of the overall treatment approach, in addition to increasing patient responsibility for their overall well being.
For more information on the use of a relapse prevention plan, you may want to go to www.cenaps.com.
Other Tools and Strategies
Some healthcare practitioners have developed other important tools and strategies for practitioners to use when doing work with eating disordered patients. (11) The Women’s Therapy Center in New York City, a leading research and practice organization for eating disorders, includes the following tools:
1) Empathic understanding of the patient’s plea
The healthcare professional needs to show compassion, but at the same time, he/she needs to show curiosity for the person’s personal and peculiar situation. He/she needs not to be judgmental, or unduly pathologize the patient.
2) Psychoeducational work
The clinician will help the patient understand the anatomy - so to speak - of his/her eating disorder, i.e., what his/her eating disorder is all about. Although some patients may know a lot about calorie content, they may not be aware of how an eating disorder affects their brain chemistry. They may not be aware either of how dieting may increase the chances of a patient’s bingeing.
It is important that healthcare professionals do not treat an eating problem just as a nutritional problem.
3) An Anti-Diet Approach to BED
This approach is the corner stone of the Women’s Therapy Center Institute philosophy and approach. Patients need to learn how to feed themselves. In order to do this, they need to eat when they are hungry, whatever they want to eat.
Under this approach, for a person to recuperate from a BED she or he, needs to eat from the inside-out, so to speak. She needs to know that if she wants chocolate, apples are not going to do it, and that if she feeds her hunger (not her emotions) she would be able to eat the chocolate and feel satiated with a normal portion.
With an anti-diet approach, patients take charge of their eating. Defendants of a behavioral approach disagree. They believe that patients with BED are not able to take charge of their eating.
Psychodynamic cognitive therapists who have worked with eating disordered patients believe that the patients respond to this approach. They also believe that in order to get better there is a need to be exposed to food and consume it to learn that food is not the enemy.
The Role of Medication in Treating BED
Another issue that clinicians may need to prepare patients for is the use of certain kinds of medications in combination with the other elements of treatment. It is important for the clinician to have the capacity to provide the patient with some detailed information about what medications might be used – including when and why – it is important for the referring clinician to be prepared to answer some rudimentary questions about the use of medications as a part of treatment.
To begin with - as we have noted a number of times in this training program - there are many disorders that exist co-morbidly with BED. Mood disorders, anxiety disorders, and impulse control problems, are just a few that we have addressed in this regard. When co-morbid conditions exist, medications for those conditions may be prescribed as part of the overall strategy for treating the eating disordered patient.
In such instances, the supervising physician or psychiatrist will be utilizing the medications in much the same manner as for any patient that presents with a mood disorder, anxiety disorder, etc. The education provided to the patient would not differ greatly from what would be given if an eating disorder was not present.
However, as eating disorders specialist Carolyn Costin points out, eating disordered patients frequently struggle with issues of control and low self-esteem. (18) The idea of taking medications presents them with a challenge, as it is an indicator of something being wrong with them, of their having flaws and imperfections. This suggests that the education about the possibility of medications may need to be approached very carefully and very gently, lest the idea of taking medication scare the patient away from the treatment that they need.
There are also times when medications may be used to treat the eating disorders directly. This is where some specialized knowledge must be known by the clinician. The long and the short of this knowledge is as follows: SSRIs medications – particularly fluoxetine (Prozac) or Fluvoxamine (Luvox) – are often going to be a helpful addition to the overall treatment plan.
Prozac does not seem to reduce the frequency of binges, but does reduce overall dietary intake. This is not from the action of Prozac to reduce hunger but to reduce the anxious, compulsive feelings that often drive hunger. Luvox was better at reducing the bingeing behaviors, based upon clinical trials. (29)
Other antidepressant medications are sometimes used to treat eating disorders, including the TCAs and the MAOIs. However, the frequency and severity of side-effects for these medications make them less appealing alternatives to the SSRIs, which are generally believed to be at least as effective, with better side effect profiles.
Medications to influence appetite and medications that work on the body's mechanisms for satiety have not yet been shown to be particularly useful. (18) However, the appetite suppressant d-flenfluramine has shown some promise in clinical trials in terms of reducing bingeing. (3)
As difficult as this is to consider, it is important for the referring clinician to stay up to date on changes in knowledge concerning the uses of medications for eating disorders, as it is with the uses of medications in other areas of treatment that may involve life threatening circumstances.
Bariatric or Gastric Surgery
A certain subset of BED patients may choose to undergo gastric surgery to address their obesity and accompanying health issues. Bariatric surgery is a procedure by which the volume of the stomach is greatly minimized making it hard, if not almost impossible, for patients to eat large amounts of food. (85)
For patients who are morbidly obese – with potentially life threatening health consequences – and who seem unable to get a handle on their over-eating, this surgery may seem like a practical solution to weight control. However, the surgery is very invasive, the recovery is lengthy, and the long-term results far from certain.
Clinicians who work with BED patients may be asked for help and guidance in deciding whether this radical intervention is a useful option. The objective perspective of the clinician can be helpful in making an informed evaluation of the pros and cons of the decision. Accordingly, it may be helpful for the purposes of this training to provide some information about this surgery and its outcomes.
To begin with, patients who suffer clinically significant BED are believed to have worse surgical outcome for bariatric surgery. (85) These patients may need additional intervention if the long term outcome of the surgery is to be improved for them. (85) This additional intervention may be a very important addition, since an estimated 30% of individuals seeking the surgery have been diagnosed with BED in comparison to 2% in the general population. (98)
Studies that have looked at the outcome of bariatric surgery in patients with BED have noted mixed results in reference to weight. Some have found that those with BED prior to surgery did better than those who did not suffer from BED. Some found the reverse. Some still found no difference between those who had BED and those who did not pre-surgically. (30)
It is important to point out that clinicians should not conclude that bariatric surgery is a cure for BED. (85) Apparently, patients with bariatric surgery lose weight and do not binge eat for a period of time after their surgery. However, it is after between 18 and 24 months following the surgery that some patients begin to regain some of the weight due to eating in a disturbed manner. (85)
For patients who are in treatment for BED, the 18-24 months before problematic eating resumes may offer an opportunity to reconfigure the emotional landscape surrounding the BED. With a reduction in the capacity for binge eating due the reduced stomach volume, the feedback loop of shame and guilt from the binge eating is temporarily interrupted. Theoretically, this may reduce somewhat the difficulty of performing cognitive restructuring and creating affective changes in the patient.
Additionally, the successful loss of weight may have positive effects on both the patient's inner life and on their interactive and interpersonal life. In fact, some studies report an overall decline in psychopathology following successful surgery. (74)
For these reasons, the option of bariatric surgery must not be discounted entirely or defined as simply giving in to vanity or the tyranny of the cultural ideals of thinness. For persons who have been obese for most of their lives – and who have suffered because of it – the potential for relief is very appealing. Clinicians should be careful to withhold judgment, and should then serve the needs of the patient by helping to do a careful evaluation of risks and rewards.
Probably, patients with significant BED before surgery have the greatest benefit after surgery due to their prior bigger gastric capacity. (43) Although the surgery does not allow these patients to binge eat after the procedure, they may graze throughout the day or ingest high caloric beverages. (57)
In other words, maladaptive ways of eating resurface after surgery. In a sense it may be a parallel to the phenomenon that happens to patients after dieting, when they begin again to eat in an out of control manner. (57)
It is important therefore to reiterate that gastric surgery is not and should not be seen as a cure for BED. (85) As a clinician working with BED it is important to inform and prepare patients of the possibility of a less than perfect outcome after bariatric surgery. It is also important to plan a strategy in case compulsive eating resumes.
Patients should be made aware of the possibility of regaining some weight and an assessment of how the patient would feel if this were to happen should be made ahead of time, as accurately as possible. In other words, a clinician's job should include helping the patient with her or his denial and see that the surgery is not a panacea even when the patient may be desperate to move forward with the surgery. The patient should be prepared to engage in ongoing treatment for BED, as well as ongoing weight management efforts.
There are a couple of other considerations that should be understood by the clinician. It is important to point out that most – but not all - surgeons pre-screen patients for BED prior to performing this procedure. However, it appears that the practices vary greatly in their methods of evaluation and identification of BED, as well as in their management of the disease once it is identified. (23)
Finally, patients must be helped to understand that there are serious risks involved in the level of invasive surgery that this procedure entails. A small number of patients do die from either the surgery or recovery from the surgery. In consulting to a patient about this surgery, it may be wise to help the patient understand the full extent of what he/she is agreeing to, and to help the patient discuss all the medical issues with his/her doctor, coming to a realistic informed consent.
Clinicians need to be prepared to deal with the issue of nutritional counseling when dealing with eating disorder patients. In general, patients with eating disorders get very anxious at the thought of using a nutritional counselor. The thought of being mandated how much to eat makes patients who suffer from eating disorders very anxious because it takes away from their main mode of coping.
Different patients will react with varying degrees of discomfort and resistance to the news of nutritional counseling and to the nutritional counseling itself, according to their level of pathology and co-morbidity. However, the referring clinician would do well in remembering that all BED patients typically use eating as the main strategy to fend off unpleasant feelings and strong emotions.
Most eating disordered patients – at least, in the USA – spend some energy in a struggle with issues of control and feeling fat - no matter their actual weight. The idea of eating in a prescribed manner presents them with a formidable challenge. The amount of the challenge they feel when faced with food is an indicator of their level of pathology. This suggests that the education about the possibility of nutritional counseling needs to be approached very carefully and very gently, lest the idea scare them away from the treatment that they need.
While it will be the responsibility of the treating clinician or treatment team – after a referral is made - to provide the patient with more detailed information about nutritional counseling– including when and why and for how long it may be needed – it is important for the referring clinician be prepared to answer some rudimentary questions about how patients may need to eat, what the food intake may be, or if they would need to see a nutritionist as a part of treatment - especially if a the patient will go into an inpatient–eating disorders unit.
Sometimes, nutritional counseling needs to be used to treat the eating disorders directly and right away, as when the eating problems are creating other kinds of life threatening medical problems. At other times, nutritional counseling can be introduced slowly after the patient has gotten used to the other elements of the inpatient unit.
If the clinician will be referring the patient to an eating disorders program where nutritional supervision will be included, he/she will need to prepare the patient for this aspect of treatment. Referring clinicians would do well to avoid making promises about any outcomes.
Body Dysmorphic Disorder affects about 2% of people in the US and strikes males and females equally.
Source: Anorexia Nervosa and Related Eating Disorders, Inc.
The Role of the Nutritionist in Treating Eating Disorders
Another component of treatment that may need to be addressed when referring a patient for treatment is what part will be played by a dietician or nutritionist. The referring clinician can help improve the odds of successful treatment by helping patients forge a positive relationship with the nutritional counselor, and avoiding potential pitfalls that may come from the patient's tendency to engage in “splitting” (this is the term used to describe the client’s defense mechanism which can pit one clinician against another).
Although today, more than ever, many people are interested in healthier eating, the eating disordered patient does not have a clear idea of what healthy eating is. Moreover healthy eating can camouflage disordered eating. Eating disordered patients may need to be given a realistic view of what a regular portion looks like or how many grams of fat are appropriate to ingest.
They may also need to be educated about the relationship between food intake and their eating problems. This would include agreements that they must eat 3 regular meals and 2 snacks per day, and/or that they must not go more than 3–4 hours without eating. To avoid these rules may mean running the risk of bingeing and feeling out of control. The nutritional counselor will teach patients how to do food exchanges and help them understand what food groups to add or subtract to have definite outcomes as far as energy or satiety goes.
However, there are some complications involved in using a nutritional counselor. Patients may hide behind the use of a nutritionist to avoid finding out their own likes and dislikes in terms of food. They may also hide behind rules in order to avoid learning about their own physiological rhythms with which they can differentiate hunger versus satiety.
Part of recovering from an eating disorder is learning to eat according to one's hunger in a manner respectful of one's physiology and taste. The journey into recovery includes eating in a safe manner that follows no strict rules. The use of a nutritionist is advisable for certain eating disorder cases and only if the nutritional counseling will end up in freeing the patient in terms of food consumption.
A nutritionist dealing with eating disordered patients need to be specialized in this field. It is not advisable to refer eating disordered patients to nutritionists who lack specialization in working with eating disorders.
Research on interrupting the binge-eating cycle has shown that once a structured pattern of eating is established, the person experiences less hunger, less deprivation, and a reduction in negative feelings about food and eating.
Source: NIMH (Citing Apple RF, Agras, WS. Overcoming eating disorders. A cognitive-behavioral treatment for bulimia and binge-eating disorder. San Antonio: Harcourt Brace & Company, 1997)