CHAPTER 8

The Treatment of Binge Eating Problems

You have now learned what we know about binge eating problems—how we define them; what types of psychological, social, and physical factors are involved in causing them; and who, as far as the research has been able to discern, is affected by them. You should also be aware that what we do not know is substantial, perhaps especially in the area of causation. It is now time for us to turn to the subject of treatment, a topic about which much more is known.

This chapter summarizes current knowledge about the treatment of binge eating problems. All the main forms of treatment are discussed, but particular emphasis is placed on the use of antidepressant drugs and a specific short-term psychotherapy called cognitive behavior therapy—commonly abbreviated as CBT—as these approaches have been the focus of particularly intense research efforts.

THE ROLE OF HOSPITALIZATION

One question that may occur to those of you whose binge eating problem has persisted despite past attempts at treatment is whether hospitalization is indicated. In fact, hospitalization is rarely appropriate. Both clinical and research experience indicate that the great majority of people with binge eating problems may be successfully treated as outpatients.

Hospitalization may not only be unnecessary, it may be counterproductive. People tend to stop binge eating soon after being hospitalized, and it is therefore easy to draw the conclusion that hospitalization is helping them overcome their eating problem. In fact, however, people tend to stop binge eating because a hospital is a foreign environment where access to food is limited, because they are protected from many of the stresses of everyday life, and because privacy is limited. In reality their binge eating is merely in abeyance. It is likely to resume after discharge.

The best inpatient programs try to prevent relapse after discharge by helping people develop skills for dealing with the processes that lead them to binge. The trouble is that the hospital environment is not a good place in which to do this. The therapist and the patient need to tackle the binge eating problem as it normally exists, that is, in the outside world.

Of course, there are circumstances under which admission to a hospital is advisable. Three stand out:

1. Some people are suicidal and so need the protection of a hospital.

2. Some people’s physical health is a cause for concern (see Chapter 5).

3. Hospitalization may also be indicated if the eating problem has not responded to well-delivered outpatient treatment.

In practice, these circumstances apply to less than 5% of cases. There is, however, one other reason for considering hospitalization. Namely, in countries without socialized health care, insurance coverage may provide the only viable means of paying for treatment, and some insurance policies only cover inpatient care. Under these circumstances, people have little choice other than to be hospitalized.

Whatever the reason for hospitalization, it should always be viewed as a preliminary to good outpatient treatment.

ANTIDEPRESSANT MEDICATION AND OTHER FORMS OF DRUG TREATMENT

Interest in using antidepressant drugs to treat binge eating problems began in 1982 with the publication of two scientific papers describing a favorable response in patients with bulimia nervosa. Since then, much research has been conducted, and the facts have become clearer.

Within a few weeks of treatment with antidepressant medication there is, on average, a 50 to 60% reduction in the frequency of binge eating. People report experiencing a reduced urge to binge. Associated with this reduction is an equivalent fall in the frequency of any associated self-induced vomiting, an improvement in mood and sense of control over eating, and decreased preoccupation with eating. These effects occur whether or not the person is depressed, but they tend not to last, whether or not the person continues to take the medication.

Research has also shown that antidepressant drugs have a selective effect on eating habits: the binge eating is affected but any accompanying dieting is not. It is likely that the persistence of dieting explains why these benefits of antidepressant medication tend not to last.

Awareness that antidepressant drugs are of limited value in the longer term has led to decreased enthusiasm for their use. However, they are still employed as a treatment for any accompanying clinical depression, and they can be extremely effective in this regard.

What about other drugs? The effects of mood stabilizing drugs such as lithium, drugs used for epilepsy, and appetite suppressants have all been studied, but none is promising. At present there is no accepted drug treatment for binge eating problems.

COGNITIVE BEHAVIOR THERAPY

In marked contrast to the research on antidepressant medication, that on psychological treatments has confirmed that they can be of considerable help. The most effective treatment is a specific form of CBT that I developed when I was training to be a psychiatrist in Edinburgh. Originally, the treatment was designed for people with bulimia nervosa but it has since been modified to make it suitable for any type of binge eating problem.

CBT is well suited to the treatment of binge eating problems because its cognitive elements address the cognitive aspects of these problems—the overevaluation of shape and weight, the dietary rules, and the all-or-nothing thinking—while its behavioral components tackle the disturbed eating habits. Its core characteristics are listed in Table 7.

CBT addresses the binge eating problem in a systematic manner by using a carefully planned sequence of interventions designed to fit the needs of the individual. It begins with the use of behavioral and educational techniques to help the person regain control over his or her eating, a key element being establishing a pattern of regular eating. This is crucial because it tends to displace most binges. However, the improvement that results is fragile because most people remain vulnerable to further episodes of binge eating. Therefore, in the second stage of the treatment the emphasis switches to reducing this vulnerability by tackling any tendency to diet and the use of binge eating to cope with adverse events and moods. The third stage focuses on maintaining the changes made and minimizing the risk of relapse.

CBT has been very extensively researched. It has been tested in studies in the United States, Canada, the United Kingdom, other countries in Europe, and in Australia and New Zealand. No other treatment for binge eating problems has equivalent support. It has also been compared with a wide range of other treatments, both pharmacological and psychological, and no treatment has been found to be as effective. Recently, in a uniquely demanding test of the latest version of CBT, so-called “enhanced CBT” or CBT-E (described later), Stig Poulsen and Susanne Lunn from Copenhagen compared 20 sessions of CBT (given over 20 weeks) with 100 sessions of psychoanalytic psychotherapy (given over 2 years). CBT-E was clearly superior, both after 20 weeks and after 2 years.

Overall, the research findings indicate that CBT has a rapid effect on binge eating. This effect is greater in magnitude than that obtained with antidepressant drugs and it persists in most cases. In common with antidepressant medication, it is accompanied by improvements in mood, concentration, and sense of control over eating. In addition, the tendency to diet decreases and concerns about shape and weight wane. These latter two effects are likely to explain why the effects of CBT tend to be enduring.

OTHER PSYCHOLOGICAL TREATMENTS

It is sometimes claimed that all psychological treatments are equally effective. This is quite untrue. Some psychological treatments have little or no impact on binge eating problems.

This said, two psychological treatments other than CBT have been shown to have consistent effects, albeit not as great as those obtained with CBT. These are interpersonal psychotherapy and “guided self-help,” a streamlined form of CBT.

Interpersonal Psychotherapy

Interpersonal psychotherapy (or IPT) is a short-term psychotherapy that focuses on helping people to improve their relationships with other people. While it was originally developed as a treatment for depression, it also helps many people with binge eating problems. How it works is uncertain, but it is certainly true that many people with binge eating problems have problematic relationships, as we discussed in Chapter 4.

When used to treat bulimia nervosa, IPT has been found to be as effective as CBT but much slower to work. The new version of CBT, CBT-E, appears to be clearly superior to IPT. The one eating disorder in which IPT may have a role is binge eating disorder, possibly because of the important role interpersonal difficulties play in triggering these people’s binges. This said, guided self-help is about as effective and much more straightforward to implement.

Guided Self-Help

Guided self-help is a streamlined form of CBT. I developed this treatment at Oxford University together with my colleague Jacqueline Carter (who has since returned to Canada). The idea of developing a simpler form of CBT sprang from the observation that a subgroup of people with binge eating problems respond rapidly and easily to CBT without much input from a therapist. It seemed that these people were able to treat themselves using CBT principles. What we therefore did was create a self-help program based upon CBT and this was published in the original edition of Overcoming Binge Eating. Part II of this book consists of an extensively revised version of the program based upon CBT-E.

The original self-help program concentrated mainly on helping people improve their eating habits. It consisted of the behavioral and educational components of CBT but it had none of the more complex cognitive elements, so it was simpler than full CBT. The program was designed to be used in two ways:

1. Pure self-help. Use of the program on its own with no external support.

2. Guided self-help. Use of the program with external support. The support need not be from highly trained therapists, as their role is confined to helping the person make the best possible use of the self-help program. Thus this is a “program-led” treatment rather than a “therapist-led” one.

These two forms of self-help have been extensively studied. The main findings are summarized below:

1. Overcoming Binge Eating is the best studied of the self-help programs for binge eating problems. Indeed, it is probably the best studied self-help program of any type.

2. In general, guided self-help is more effective than pure self-help, although some people are able to treat themselves.

3. Guided self-help is remarkably effective as a treatment for binge eating disorder and related states (e.g., see Box 13).

4. There has been less research on the use of guided self-help in the treatment of bulimia nervosa and the atypical eating disorders, and the findings are somewhat inconsistent. This said, it is clear that it is effective in substantial numbers of cases.

Guided self-help has many advantages over more conventional forms of therapy. These include being relatively inexpensive and more readily accessed as it does not require a highly trained therapist. Pure self-help has yet further advantages as it totally sidesteps some of the barriers to obtaining treatment, including cost, absence of local treatment resources, and difficulty attending appointments. In addition, pure self-help allows people to receive “treatment” at a time, place, and pace that suits them. Last, but not least, it has the advantage of being inherently empowering. Overall, both forms of self-help have much to commend them.

WHEN TO USE SELF-HELP

What conclusions can we draw from the research on the treatment of binge eating problems, and where does self-help fit in?

The most important point to emphasize is that if you, or someone you know, is seeking professional help for a binge eating problem, the treatment of choice is CBT on a one-to-one basis and, ideally, CBT-E. (The website www.credo-oxford.com provides up-to-date information on the treatment.) Most people benefit substantially, and in the majority of cases the changes last. It must be stressed, however, that some people do not improve or they make only limited gains. These people need additional help. On the other hand, substantial numbers respond to simpler approaches, such as pure or guided self-help.

Given the research findings, a “stepped care” approach to treatment delivery seems sensible with a simple treatment being used first, and with more complex ones only being employed if the simple one proves ineffective. Thus, in the case of recurrent binge eating, the two steps are as follows:

• Step 1. Self-help (guided or pure)

• Step 2. One-to-one therapy, ideally CBT or CBT-E

This strategy is evidence-based and applies across all types of binge eating problem unless you are underweight. If you are underweight (i.e., have a BMI below 18.5; see “Getting Ready,” Table 8), you should seek professional advice because self-help on its own is unlikely to be sufficient.

WHY USE THIS SELF-HELP PROGRAM?

Why use the self-help program in Part II? There are two reasons. First, as mentioned already, the original self-help program published in Overcoming Binge Eating is the best tested program available. Second, the new version of the program takes account of advances in the understanding of binge eating problems, advances that have been reflected in the development of the “enhanced” version of CBT, CBT-E. CBT-E includes a new way of conceptualizing eating problems, improved ways of regaining control over eating, a more sophisticated approach to the addressing of concerns about shape and weight, and much more emphasis on relapse prevention. The self-help program in Part II is, in essence, a self-help version of CBT-E.