Psychotherapy Brown Bag

Mortality rates in eating disorders: adding EDNOS to the equation

by Joye C. Anestis

By now it's pretty much common knowledge that eating disorders are devastating.  For instance, we know that anorexia nervosa (AN) has the highest mortality of any psychiatric disorder (10%; APA, 2004).  Surprisingly, most of these deaths are by suicide, not medical complications associated with starvation (e.g.,Crisp, Callendar, Halek, & Hsu, 1992; Fedorowicz et al., 2007).  The mortality rate for bulimia nervosa (BN) is lower (approxiamtely 0.3%; Keel & Mitchell, 1997), although suicide attempts are highly elevated with this diagnosis (1/3 of women with BN will attempt suicide at least once; e.g., Corcos et al., 2002; Franko et al., 2004).  Less is known about the mortality rate for eating disorder not otherwise specified (EDNOS), the most common eating disorder diagnosis.  This catch-all category consists of almost any pathological eating behaviors that do not fit the criteria of AN or BN (e.g., binge eating disorder, purging disorder, night eating syndrome).  Scott Crow and colleagues recently examined the mortality rate in all eating disorders, and specifically in EDNOS, to cover this gap in our knowledge (the article, from the December 2009 issue of American Journal of Psychiatry can be accessed here).  

Subjects in this study were individuals who presented to the University of Minnesota Outpatient Eating Disorders Clinic between 1979 and 1997 (n = 1,885).  Each client at this clinic completed the Eating Disorder Questionnaire and reported their Body Mass Index (BMI).  These 2 pieces of information were used to generate diagnoses of a current ED (and this reliance on self-report to make diagnoses is a significant limitation to the study that should be considered).  To obtain mortality information, the researchers examined the National Death Index, a computerized database of state vital statistics data compiled by the National Center for Health Statistics.  Updated yearly, it provides vital status information for the entire United States.  Crow and colleagues were able to search this database and classify causes of death into 4 groups: suicide, substance-use related, traumatic, and medical.

The entire sample was overwhelmingly female (95.1%) and white (94.9%).  BN was the most common diagnosis (48.1%), followed by EDNOS (42.5%) and then AN (9.4%).  The mortality rate for BN was 3.9%, which is higher than is generally found, while the mortality rate in AN was lower than expected at 4.0%.  But the main focus of the study was on EDNOS - where they found a mortality rate higher than most would have expected at 5.2%.  Along with reported percentages of death, the authors also calculated  standardized mortality ratios, which they describe as "the ratio of the observed rate of deaths in a population divided by the expected rate, based on the sample's demographic characteristics" (pp. 1343-44).  The standardized mortality ratios for all deaths were 1.70 for AN, 1.57 for BN, and 1.81 for EDNOS.  They also reported separate standardized mortality ratios for deaths by suicide.  They were 4.86 for AN, 6.51 for BN, and 3.91 for EDNOS.  They noted that the elevated suicide risk for AN was not statistically significant, but the elevated risks for BN and EDNOS were significant.

The most interesting and novel finding reported here is the significant number of deaths by suicide in the EDNOS sample - a rate similar to that found in individuals with AN.  It is (I hope) common knowledge within the mental health community that AN is an incredibly lethal illness (see this previous post for a brief discussion about why AN is so lethal, above and beyond the effects of starvation).  The authors note that many perceive an EDNOS diagnosis to be less severe than other eating pathology, and these findings emphasize the fallacy in this perception.  Suicide risk should always be assessed and monitored in EDNOS patients, just as in all patients with mental health problems.  One downfall of this study is that they did not report subgroups of individuals within the EDNOS category.  EDNOS is an incredibly heterogeneous group of behaviors, including individuals who meet criteria for AN except that they have regular menstrual cycles or their weight is in the "normal" range, individuals who meet criteria for BN except that they binge and purge less frequently than the DSM requires, folks with purging disorder, folks who chew and spit out their food without swallowing, and individuals with binge eating disorder.  I think it would have been very interesting to see if certain types of behaviors (e.g., purging disorder) were carrying much of the suicide risk.  Another notable limitation, and one which could have influenced the elevated mortality risk, is that obese individuals with binge eating disorder were referred to a different clinic.  This could have led to a skewed EDNOS sample.

This study also found a lower mortality rate for AN than previous studies.  The authors note that this could be the result of methodological differences between their study and others.  The current study used a current diagnosis of AN, whereas previous studies have used lifetime diagnoses.  In fact, when the authors reexamined their data using lifetime diagnoses, the standardized mortality ratios for all death and death by suicide both increased and became significant.  Furthermore, these were outpatient clients, and perhaps more serious cases of AN would be more likely to seek treatment at an inpatient facility.  

In sum, Crow et al.(2009) present evidence that suicide risk and overall mortality in EDNOS should be examined more closely.  I bet, with the upcoming release of DSM-V and the revamping of the eating disorder section, more research into this heterogeneous category will be conducted.

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.

Eating disorders and DSM-V

by Michael D. Anestis, M.S.

I hope everyone enjoyed their Thanksgiving holiday.  We certainly enjoyed our time off, but are excited to return to PBB.  Given the amount of time I spent thinking about food during this past week, with mashed potatoes playing a particularly prominent role in my thoughts, I figured it might make sense to keep food at the center of today's discussion.

In the current issue of the International Journal of Eating Disorders, a number of prominent researchers published articles discussing proposed changes for eating disorder diagnoses in the upcoming DSM-V.  Several articles discussed the potential inclusion of binge eating disorder in the main text of the DSM (it is currently listed as a disorder in need of further research and results in a diagnosis of eating disorder not otherwise specified) and the addition of purging disorder and night eating syndrome as well.  The article that interested me the most, however, was written by Timothy Walsh and Robyn Sysko (2009) of Columbia University and discussed a proposed overhaul of the eating disorder diagnostic system for DSM-V.

Before explaining their proposed system, Walsh and Sysko (2009) took care to explain why they believe such changes are necessary.  As it stands, the DSM formally recognizes two eating disorder diagnoses: bulimia nervosa (BN) and anorexia nervosa (AN).  As I mentioned above, binge eating disorder (BED) is listed in the appendix as a disorder in need of further research, so no formal BED diagnoses exists.  Instead, individuals who meet criteria for BED receive a diagnosis of eating disorder not otherwise specified (EDNOS).  At first glance, this might not seem all that problematic, but there are a number of other issues that clarify why this needs to be addressed.  Research has demonstrated that between 50% and 70% of eating disorder diagnoses are EDNOS (Ricca et al., 2001; Turner & Bryant Waugh, 2004).  In other words, the majority of individuals with an eating disorder do not meet criteria for one of the two eating disorders recognized by the DSM.  As such, the catch-all residual category of EDNOS accounts for an absurdly large proportion of patients.

The problems of EDNOS are not limited to the fact that it accounts for such a high percentage of eating disorder diagnoses, however.  Perhaps even more problematic than that is the fact that the category itself is so broad.  Walsh and Sysko (2009) pointed out that a 14-year-old girl who meets all of the criteria for AN except that she reports menstrual activity and a 46-year-old man with BED would both be given a diagnosis of EDNOS despite the fact that these two individuals have very little in common.  In other words, knowing that somebody has EDNOS tells us very little about who they are and what symptoms are causing them distress and/or impairment and yet this diagnosis is nonetheless what we are most likely to see listed in the case file for a patient with an eating disorder diagnosis.

Walsh and Sysko (2009) were thus determined to develop a diagnostic system for eating disorders that would result in substantially fewer individuals being given an EDNOS diagnosis but which would not reduce the validity of the diagnoses or cause a disconnect between current research and the new diagnoses.  Their proposed model, which they named the Broad Categories for the Diagnosis of Eating Disorders (BCD-ED) involves three hierarchical categories mirroring the current most researched eating disorder diagnoses and also retains a much more limited EDNOS category.  They defined the categories as follows (pg.755):

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Anorexia Nervosa and Behaviorally Similar Disorders (AN-BSD)

"An eating disorder category characterized by the restriction of food intake relative to caloric requirements resulting in the maintenance of an inappropriately low weight, not better explained by a general medical condition or another psychiatric disorder.  The prototype for this category is an individual meeting DSM-IV criteria for AN."

Bulimia Nervosa and Behaviorally Similar Disorders (BN-BSD)

"An eating disorder category characterized by recurrent out of control eating and the recurrent use of inappropriate purging methods to control eating or weight.  The prototype for this category is an individual meeting DSM-IV criteria for BN."

Binge Eating Disorder and Behaviorally Similar Disorders (BED-BSD)

"An eating disorder characterized by recurrent episodes of out of control eating.  The prototype for this category is an individual meeting DSM-IV criteria for BED."

Eating Disorder Not Otherwise Specified (EDNOS)

"A residual diagnostic category for all other individuals with a clinically significant eating disorder."

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So, Walsh and Sysko's (2009) model essentially involves shifting BED from the appendix to the main text of the DSM and including sub-threshold patients in the broader eating disorder categories rather than giving them an EDNOS diagnosis.  In other words, an individual meeting all the criteria for AN except that she reports menstrual activity would now receive an AN-BSD diagnosis instead of EDNOS and an individual who frequently binge eats and purges, but averages less than twice per week would receive a diagnosis of BN-BSD rather than EDNOS.

Without question, this would result in a smaller proportion of eating disorder patients receiving EDNOS diagnoses, but the authors acknowledged two other issues that require attention.  First, does the hierarchical structure of their model make sense?  And second, would this shift result in an over-diagnosis of eating disorders because it is so broad?

The first question, which essentially asks whether AN is more severe than BN and whether BN is more severe than BED, is difficult to answer.  For one thing, the authors could find not studies that specifically addressed that particular question.  Secondly, it would be difficult to determine the relative danger of mild AN compared to severe BN, particularly if we are not also considering comorbid diagnoses, prior history of suicidal behavior, and prior responses to treatments.  The authors openly admitted that this is a bit of a blurry issue; however, they also provided some evidence supporting their decision to structure the model in this manner.  For one thing, of all the eating disorder classifications, AN involves the highest mortality (Hoek, 2006) and medical complication (Mitchell & Crow, 2006) rates and also the poorest treatment response and greatest rate of relapse.  The picture is a bit less clear with respect to BN and BED, with some studies indicating that BN is more severe with respect to prognosis (Fairburn, Cooper, Doll, Norman, & O'Connor, 2000; Hay & Fairburn, 1998) and others not supporting any difference between the categories (Fitcher Quadfleig, & Hedlund, 2008).  So, support for listing AN-BSD as the most severe is fairly strong, but support for the hierarchical structure of BN-BSD and BED-BSD is less compelling.

The second question - whether this new system would result in the over-diagnosis of eating disorders - is equally difficult to answer, as there is no way to conclusively predict the future.  On the one hand, the broad nature of the categories might cause some clinicians to give a diagnosis they otherwise might not give.  On the other hand, these new categories do not seem any more broad than the standard EDNOS diagnosis, so I am not certain I see any reason to believe there would be a sudden surge in diagnoses unless clinicians are simply wary of diagnosing EDNOS but somehow more willing to provide an questionable diagnosis of another eating disorder (and there are no data I am aware of that indicate this is the case).  Regardless, Walsh and Sysko (2009) proposed that, in an effort to prevent over-diagnosis, the DSM-V should include specific criteria requiring functional impairment as a direct result of disordered eating.  In other words, the DSM-V should be clear about what constitutes clinically significant distress and/or impairment so as to help clinicians determine if a particular patient warrants a diagnosis (e.g., does the client exhibit an "inappropriately low" weight?  Does the client binge eat often enough?).

On the whole, I think that this model is imperfect, but a great idea.  Reducing the reliance upon EDNOS is an important goal for DSM-V.  I do, however, have a couple of concerns that went unaddressed in the Walsh and Sysko (2009) article.  First, in their definition of BN-BSD, they mentioned that the client must exhibit "purging" behaviors whereas DSM-IV requires "inappropriate compensatory behaviors."  Purging involves attempts to immediately expel what was previously consumed (e.g., self-induced vomiting, the use of laxatives) whereas the broader category of compensatory behaviors can include non-purging behaviors aimed at weight control such as excessive exercising and fasting.  Does the Walsh and Sysko (2009) model thus require a reclassification of some individuals who would otherwise meet criteria for BN and, if so, is such a change justified (e.g., do individuals with purging versus non-purging BN respond differently to different treatments?)?  Additionally, the new model does not address the issue of purging disorder.  Night eating syndrome seems likely to end up in the BED-BSD category, but purging disorder seems likely to still result in an EDNOS diagnosis.  It might be that Walsh and Sysko (2009) want to see more research conducted on purging disorder before it is added so definitively to an eating disorder diagnostic scheme, but I would have liked to see them discuss that issue in order to clarify the point.

In the other DSM-V models we have discussed on PBB (mood and anxiety disorders, personality disorders, PTSD, autism spectrum disorders), the proposed changes have been fairly radical in nature.  The eating disorders proposal, on the other hand, is fairly conservative.  Walsh and Sysko (2009) did an admirable job of proposing a system that would reduce reliance upon the EDNOS diagnosis and cluster similar behaviors with one another.  That being said, do you see any strengths and/or weaknesses that went unaddressed in this discussion?  Do you have a suggestion for an alternative model?  Do you think changes to the system are even necessary in the first place?  We look forward to hearing your thoughts.

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If you would like to learn more about eating disorders and their treatment, we recommend the following items, all of which are available through our online store of scientifically-based psychological resources:

• Cognitive Behavior Therapy and Eating Disorders by Christopher Fairburn

• Overcoming Binge Eating by Christopher Fairburn
  

• If Your Adolescent Has an Eating Disorder: An Essential Resource for Parents by Timothy Walsh
  

• Treatment Manual for Anorexia Nervosa: A Family-Based Approach by James Lock, Daniel le Grange, Stewart Agras, and Christopher Dare
  

• Eating with Your Anorexic: How My Child Recovered Through Family-Based Treatment and Yours Can Too by Laura Collins
  

• Dialectical Behavior Therapy for Binge Eating and Bulimia by Debra Safer, Christy Telch, and Eunice Chen
  

• Eating Disorders by Pam Keel

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Some PBB press - Maudsley Parents names PBB their website of the month

We want to extend a warm thank you to MaudsleyParents.org for naming PBB their website of the month.  We highly recommend that readers check out their website and newsletter, both of which are great resources for information on family-based treatment.  The organization emphasizes evidence-based approaches to treatment for eating disorders and displays a simultaneous devotion both to clinical practice and an up-to-date understanding of scientific research.  In our minds, such balance embodies exactly what this field should be striving for professionally.

Thanks again.

Mike and Joye Anestis

Internet-based cognitive behavioral therapy for adolescents with bulimia nervosa: Can it work?

by Michael D. Anestis, M.S.

In the current issue of Behaviour Research and Therapy, Natalie Pretorius and colleagues (2009) published a study that examined the degree to which an internet-based approach to cognitive behavioral therapy (CBT) might prove useful in the treatment of bulimia nervosa (BN) in adolescents.  As we have discussed on PBB in prior articles, Division 12 of the American Psychological Association lists CBT as one of the gold standard treatments for BN, describing its research based, as well as that of interpersonal psychotherapy (IPT), as strong.  Like most other mental illnesses, however, a significant number of individuals who meet criteria for BN do not seek treatment.  This is true for a variety of reasons, including shame about symptoms, stigma about seeking treatment, and a lack of effective diagnostic procedures and treatment referrals in primary care environments.  Finding ways to increase remote access to empirically supported treatments (ESTs) thus appears to be of potentially great value, as this would allow individuals to privately seek treatment in an environment of their choosing. Along these lines, James Mitchell and colleagues (2008) found that there was no statistically significant difference in outcomes for individuals who received CBT over the phone compared to those who received CBT face-to-face, thereby offering empirical support for the potential value of remote treatments.  Such findings provide a strong rationale for examining other forms of remote treatments, including those based on the internet.

Pretorius and her colleagues (2009) thus attempted to examine the degree to which the apparent potential of web-based CBT would translate to actual results.  To do so, they recruited a sample of 101 participants (98 females, 3 males) from eating disorder clinics across the United Kingdom as well as from BEAT (Beating Eating Disorders), a charity specializing in helping individuals with eating disorders find useful resources.  All participants were diagnosed through a semi-structured clinical interview and met DSM-IV-TR criteria for either BN or eating disorder not otherwise specified with bulimic symptoms (EDNOS-BN).  Individuals in the latter category either did not binge or purge often enough to meet BN criteria (on average twice per week for at least three months) or they used compensatory behaviors in the absence of objective binges.  All participants were between the ages of 13 and 20.

The treatment itself consisted of eight interactive online sessions, each of which required 30-40 minutes to complete.  Based upon their responses to interactive sections of each session, participants received personalized feedback.  In addition, each participant was provided with workbooks, homework, and an audio session on controlling anxiety to accompany each session.  Participants were able to access an online message board moderated by the researchers in order to ensure peer support throughout treatment.  Additionally, participants received weekly email support from a therapist trained in CBT.

The results from this study, while promising to some degree, were fairly mixed.  17% of the participants did not complete a single web-based session and the average number of sessions completed was only 3 out of 8.  In other words, on average, participants took part in less than half of the treatment protocol.   Follow-up data was attained at three months and six months after the initial interview; however, only 51.5% of the sample provided information at the 3-month and only 62.3% provided information at the 6-month.  So, in addition to the large number of individuals who did not complete much or any of the treatment, many individuals did complete treatment did not report on their symptoms throughout the course of the study. 

Despite the low level of overall participation, the authors were able to examine the impact of treatment on BN symptoms.  Participants showed improvement on their number of objective binge episodes, vomit episodes, laxative episodes, overall eating disorder symptoms levels, and body mass index (BMI).  This is promising; however, a closer look at the numbers diminishes that promise quite a bit.  At baseline, 1% of the sample who ended up completing treatment had been free of objective binges, vomiting, and laxative use for one month.  At three months, this number increased to 10%.  At six months, the number increased to 17%.  When the authors looked at a less stringent outcome measure - percentage of participants who were either abstinent from or sub-clinical in binge episodes, vomiting, and laxative use - the numbers improved a bit.  9% met this criteria at baseline, 25% at three months, and 29% at six months.  When the entire sample was considered, those numbers decreased.

So, 71% of the sample that completed treatment still utilized binge eating, vomiting, and/or laxatives at a clinically significant level and 83% reported that they were using these behaviors at least sub-clinically.  These numbers, quite frankly, are unimpressive. As a comparison, face-to-face CBT tends to result in abstinence rates of 30-50% and a reduction of binge eating and purging behaviors of 80% (Wilson & Fairburn, 2002).  In one of the better trials of CBT for BN, Wilson, Fairburn, Agras, Walsh, and Kraemer (2002) found that, on average, purging behaviors were reduced by 62% and binge eating was reduced by 72%.  Clearly then, Pretorius and colleagues (2009) did not find results for internet-based CBT that compare to traditional face-to-face therapy.  Additionally, because the authors did not have any form of control group, there is absolutely no way to determine the degree to which the internet-based treatment had any impact on BN symptoms.  For all we know, the meager improvements were better accounted for by the mere passage of time.

Are these results consistent across other studies using adult populations?  Not necessarily.  Studies using adult samples have produced somewhat better results.  For instance, Fernandez-Aranda and colleagues (2009) found that, while only 15% of participants receiving internet-based CBT for BN abstained from binge eating and purging after one month, the overall rates of abstinence for binge eating and purging after three months were 55% and 73% respectively.  Similarly, Ljotsson and colleagues (2007) found a 64% decrease in objective binge episodes for individuals who received a copy of the book Overcoming Binge Eating as well as email support and access to a moderated message board.

So, what do we know overall about the use of CBT to treatment BN?  First of all, face-to-face CBT is an effective treatment that tends to produce strong results.  Additionally, there is compelling evidence that CBT can be effectively administered over the phone and, for adults, the internet may also be a successful medium for treatment delivery.  The Pretorius et al. (2009) study, however, indicates that internet-based CBT is not yet an effective method for the treatment of BN in adolescents.  Alterations to the protocol need to be made in order to ensure a greater level of participation by the client as well as a significantly greater level of symptom reduction.  So, if an adolescent is showing signs of BN, the best course of action remains seeking face-to-face help from a therapist trained in empirically supported treatments.  If you would like to find such resources in your local area, please consult our EST clinics page.

If you would like to learn more about empirically supported treatments for bulimia, we recommend the following resources, all of which are available through our online store:

Overcoming Binge Eating - Christopher Fairburn, DM, FMedSci, FRCPsych

Cognitive Behavior Therapy and Eating Disorders - Christopher Fairburn, DM, FMedSci, FRCPsych

Crave: Why You Binge Eat and How to Stop - Cynthia Bulik, Ph.D.

Dialectical Behavior Therapy for Binge Eating and Bulimia - Debra Safer, M.D.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Binge eating: How do we distinguish a binge from simply overeating?

by Michael D. Anestis, M.S.

The word "binge" is ubiquitous.  We hear people referring to binges in a variety of contexts with respect to a multitude of behaviors and yet, generally speaking, the precise definition of "binge" remains vague.  Certainly, everyone who uses this term is referencing something large, but that does not leave much room for differentiating between a clinically relevant behavior (e.g., binge eating) and a normative behavior (e.g., Thanksgiving dinner). The purpose of today's article is to provide some clarity on this topic, with a particular focus on the definition and nature of binge eating.
According to the DSM-IV-TR, a binge eating episode has two defining characteristics.  The first is that more food is consumed in a discrete period of time than would typically be consumed by others in that same period within the same context.  A discrete period of time is, admittedly, a fairly broad term, although the DSM further specifies that a single episode should last less than two hours.  The second defining characteristic is that the individual experiences a perceived loss of control during the episode.  Having spent a significant amount of time discussing the nature of binge eating with both clients and students, I have found that a fairly distinct pattern of questions almost invariably emerges.  As such, I would like to address several of these questions here.

Why does the DSM specify the need to consider context?  Isn't a binge a binge regardless of where or when it happens?

    A binge is, indeed, a binge, but context is nonetheless important to consider.  One way to think about this, as alluded to above, would be to consider holiday meals.  Most of us consume a considerably above average amount of food during Thanksgiving dinner.  This, however, does not necessarily represent a binge because, contextually, it is a normative behavior.  Thanksgiving dinner is a ritualized, culturally-bound phenomenon that encourages excess in one particular instance.  This is not to say that Thanksgiving dinner can not still represent overeating; however, as my answers to subsequent questions will help clarify, overeating and binge eating are distinct from one another.  An individual can binge during Thanksgiving dinner if they meet all of the binge criteria, but simply eating a lot on Thanksgiving does not necessarily qualify as binge eating.

I've done this before.  Does that mean I have an eating disorder?

    Absolutely not.  To meet criteria for bulimia nervosa (BN) or binge eating disorder (BED), the DSM-IV-TR requires that the binges occur, on average, twice per week for a period of no less than three months. It is not at all uncommon for an individual to report that they have experienced one ore more binge episodes in their lifetime.  For this to have clinical significance, however, it needs to be a recurrent pattern that causes distress and dysfunction in the individual's life.  If an individual "tried out" the behavior in response to social pressure, body dissatisfaction, a mood disorder, or any other prompting event but did not continue, that individual would not meet criteria for BN or BED.  If the binges are infrequent but cause distress and/or impairment, a clinician may consider a diagnosis of eating disorder not otherwise specified (EDNOS), but this is an unlikely presentation.

What do you mean, loss of control?  Can't people just stop eating when they want to?

A key point here is that the loss of control is perceived by the individual.  Yes, it is always physically possible to stop eating, but a variety of individuals are predisposed to under controlled, dysregulated behaviors.  I've had clients who binge eat explain to me that, when they started a binge, it felt as though a wave was coming towards them and they could do nothing to stop it from crashing ashore.  This perceived lack of control can be conceptualized as a difficulty inhibiting behaviors.  Essentially, for folks who binge eat, it is as though they are driving a car and their brake pedal is faulty - so they are not necessarily speeding towards the binge, but they struggle to stop the event from happening once they are in motion.  A variety of characteristics have been shown to predict who is vulnerable to developing patterns of under controlled eating, including high levels of negative urgency (which we will discuss in detail in future posts) and low levels of distress tolerance (Anestis, Selby, & Joiner, 2007; Anestis, Selby, Fink, & Joiner, 2007; Fischer, Anderson, & Smith, 2004).
    The perceived loss of control is important to consider when attempting to distinguish between clinically relevant binge eating and normative eating experiences.  When I go to Cheeburger Cheeburger on Sanibel Island, Florida, I often decide to order the one pound burger so as to get my picture placed on the wall.  This behavior is thus planned ahead of time and represents a careful decision on my part.  The premeditated nature of the behavior, in part, serves to disqualify this meal as a binge.  Even more so, however, my ability to stop when I feel full is what makes this particular meal not fit the category of binge eating.  When the burger is too much - which happens from time to time - I simply stop.  I do not feel compelled to continue.  When an individual binge eats, she often feels as though the behavior is simply happening, almost as though she is a spectator with no control over the outcome.

A spectator?  What could that possibly mean?

    A very legitimate question.  How can an individual be a spectator to their own behavior?  In reality, this does not mean the individual is watching the behavior take place as though it was occurring on television.  Instead, it refers to dissociation.  We will write in more detail on dissociation in future posts, but for the sake of clarity, I will provide a brief description here.  Dissociation is a state of mind in which individuals feel disconnected from and often do not attend to their immediate environments.  We all do this from time to time.  Have you ever been driving and realized that you do not remember the past five minutes of your trip?  Have you ever been in a conversation and suddenly realized that your mind had wandered elsewhere and you have no idea what the other individual is saying?  These are mild examples of dissociation.  For some individuals, stress can induce a more troubling form of dissociation, in which what is happening feels unreal, almost as though it was a dream.
    For individuals who binge eat, dissociation is a common experience.  As such, they do not savor the food they are eating, enjoy the experience as it is happening, or feel capable of enacting any degree of control over the behavior. In earlier posts discussing dialectical behavior therapy (DBT), we mentioned that there is compelling empirical evidence that DBT is an effective treatment for bulimia nervosa (BN) and binge eating disorder (BED), both of which are characterized by frequent binge eating.  One explanation for this might be the emphasis on mindfulness, which teaches individuals skills for remaining focused on neutral present stimuli and can help prevent or diminish dissociative experiences.

What if somebody says they binge eat but they actually do not eat large quantities of food?

    This is a very common phenomenon.  As such, clinicians are taught to differentiate between objective and subjective binge episodes.  Objective binge episodes meet the criteria detailed above.  Subjective binge episodes, on the other hand, involve perceptions on the part of individuals that they binge ate when, in fact, they did not eat enough food to qualify for an objective binge.  Oftentimes, individuals who have eating disorder or who are dieting have a "banned foods" list.  For some individuals, eating even a single item off of this list constitutes a binge, regardless of the caloric intake.  Interestingly, there is some evidence that the perceived lack of control is more important than the actual size of the episode and that, while it is important to distinguish between objective and subjective binges in order to ensure accurate perceptions of the impact of consuming particular foods, subjective binges are equally problematic (Keel, Mayer, & Harnden-Fischer, 2001).

What disorders are characterized by binge eating?

    Binge eating disorder (BED) is a disorder characterized by binges that occur, on average, at least twice per week for a period of no less than three months.  Individuals with BED do not engage in compensatory behaviors aimed at counteracting binge eating episodes (e.g., self-induced vomiting, abuse of laxatives, excessive exercise).  Bulimia nervosa (BN) is a disorder characterized both by recurrent binge eating episodes (same frequency requirement as BED) as well as compensatory behaviors aimed at counteracting the effects of a binge.  Anorexia nervosa (AN) includes two subtypes.  The first, restrictive type, does not involve regular binge eating.  The second, however, is referred to as binge-eating/purging type and does involve regular binge eating.  The difference between binge-eating/purging type AN and BN is that individuals who meet criteria for the former are severely underweight whereas individuals who meet criteria for BN are typically of normal weight.
    Importantly, although eating disorders are significantly more common in women than in men, there is evidence that there are no sex differences in rates of binge eating behaviors (Striegel-Moore & Franko, 2003).

Is there really any difference between obese individuals without an eating disorder and obese individuals with binge eating disorder?

    Wilfley, Wilson, and Agras (2003) provide a thorough review on this topic.  Obese individuals with BED consume more calories during binge episodes and non-binge meals than do weight-matched individuals without an eating disorder (Yanovski, 2002).  Additionally, obese individuals who meet criteria for BED are three times more likely than obese individuals without an eating disorder to meet criteria for depression (Telch & Stice, 1998).  As such, a classification of binge eating disorder is not simply putting a label on being obese.  Instead, it is calling attention to a distinct subset of individuals who are particularly vulnerable to a variety of problematic outcomes.

What prompts individuals to binge eat?

    There are a variety of things that can cause an individual to binge eat, but one of the most well supported precipitating factors is negative affect.  Several studies have shown that binge episodes are typically preceded by highly negative moods.  Additionally, although not universally supported, some studies indicate that, in addition to being preceded by states of negative affect, binge eating episodes are followed by immediate reductions in negative affect, which reinforces the use of the behavior (Smyth et al., 2007).  So, although not all binge episodes are prompted by negative moods, it appears that emotions play a pivotal role, which explains why interventions such as DBT, which teach emotion regulation skills, have shown such strong results. 

How do individuals who binge eat feel about their behavior?

    It is important to consider this question.  Typically, individuals who struggle with binge eating are highly ashamed of their behaviors.  They binge eat in secrecy and avoid social situations that might involve eating.  In treatment, clinicians sometimes struggle to motivate the client to involve peers and/or family as a support system because the client feels such shame.  Clients who binge eat often feel like a "freak," so it is important to educate them on how common this behavior is and to demonstrate that there is no evidence supporting their belief that peers and family will refuse to help.


There are many other questions that come up when I talk about binge eating with clients and students.  Can you think of others?  Are there answers to these questions that you think I may have overlooked in this article?  I encourage you to share your thoughts with other readers through the comment section.  Ideally, I would love for this to be a conversation involving a variety of perspectives and experiences.  I can think of no better way to encourage a broad, thorough education on this important topic.

If you would like to learn more about binge eating, we encourage you to explore the following resources, all of which are available through the Psychotherapy Brown Bag online store:

Books:

• Crave: Why You Binge Eat and How to Stop

• Overcoming Binge Eating

• Overcoming Your Eating Disorder: A Cognitive-Behavioral Therapy Approach for Bulimia Nervosa and Binge-Eating Disorder, Guided Self Help Workbook (Treatments That Work)

• Dialectical Behavior Therapy for Binge Eating and Bulimia

• Overcoming Eating Disorders: A Cognitive-Behavioral Therapy Approach for Bulimia Nervosa and Binge-Eating Disorder Therapist Guide (Treatments That Work)

• Binge Eating: Nature, Assessment, and Treatment

• Binge-Eating Disorder: Clinical Foundations and Treatment

Kindle:

• Overcoming Your Eating Disorder: A Cognitive-Behavioral Therapy Approach for Bulimia Nervosa and Binge-Eating Disorder, Guided Self Help Workbook

• Binge-Eating Disorder: Clinical Foundations and Treatment

• Eating Disorders, Anorexia, Bulimia, Causes, Symptoms, Signs, Diagnosis and Treatments

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

It's just too much for me: The role of distress tolerance in problematic behaviors

by Michael D. Anestis, M.S.

    There are a variety of ways in which our emotions can cause us difficulties.  For some of us, affective lability - rapidly shifting emotional states - is the problem, leaving us in an unpredictable, frequently aversive state that feels difficult to control.  Others of us experience more frequent or more severe negative moods, so we encounter more powerful emotions more often than others.  For some of us, the problem is alexithymia - an inability to effectively identify our emotions, which leads to a broad sense of feeling "bad" that is difficult to regulate.  For others of us, the problem is anhedonia, an inability to feel positive emotions in response to things that previously felt pleasurable, which leaves us feeling numb, disconnected, and unmotivated.  There are several other ways in which our emotions can cause us problems and an entirely comprehensive list would be almost impossible.  Today, I will focus on one particular emotional variable, distress tolerance, which is defined as the degree to which an individual experiences emotions as overwhelming (Simons & Gaher, 2005).
    When I explain distress tolerance to a client or student, I tend to start with a bit of an odd metaphor.  I tell the person to imagine each person is a glass of water.  Each glass is uniform, holding the exact same amount of liquid, and each glass is sitting under a faucet that pours water out at the same rate.  Next, I tell the person to imagine that my glass of water starts with more water in it than any other glass.  Given this situation, even though my glass is being filled at the same rate with the same amount of water, mine will overflow more quickly than other glasses.  In this metaphor, my glass has low distress tolerance.  When an individual has low distress tolerance, it's not that he experiences more powerful emotions, more frequent negative emotions, or more confusing emotions.  The issue is simply that, what does not feel overwhelming to others feels overwhelming to him.  His glass already has more water in it, so it takes less to overflow.
    Fortunately, there is a lot of empirical research on distress tolerance that does not rely on my glass metaphor.  In this research, scientists have found that low levels of distress tolerance predict a host of problematic behavioral outcomes.  Women tend to have lower levels of distress tolerance than men, but low distress tolerance is equally destructive regardless of sex (Simons & Gaher, 2005), much like rumination.  Brandon and colleagues (2003) found that smokers with low distress tolerance were less able to sustain quit attempts than were smokers with moderate or high levels of distress tolerance.  Similarly, Daughters, Lejuez, Kahler, Strong, and Brown (2005) found that individuals with low distress tolerance receiving treatment at a substance abuse treatment facility were less able to sustain quit attempts than were individuals at that same facility with higher levels of distress tolerance.  Additionally, in a separate study, Daughters and colleagues (2005) found that individuals with low distress tolerance were more likely to drop out of a substance abuse treatment facility.  These findings make a lot of sense and go a long way towards explaining why overcoming addiction is more difficult for some individuals than others (although by no means explains it all).  Withdrawal is an extremely uncomfortable, distressing experience.  If an individual is already inherently less able to tolerate even moderate levels of distress, this experience becomes that much more difficult.
    Distress tolerance has been shown to be important in several other behavioral outcomes as well.  Daughers and colleagues (2005) found that pathological gamblers with low distress tolerance were less able to sustain quit attempts.  In a paper I co-wrote with Eddie Selby, Erin Fink, and Thomas Joiner (2007), we found that individuals with low distress tolerance were more likely to binge eat and purge than are individuals with higher levels of distress tolerance.  Nock and Mendes (2008) found that individuals with who frequently engage in non-suicidal self-injury (NSSI) also have low levels of distress tolerance, which is particularly problematic given the relationship between NSSI and the acquired capability for suicide.  Given all of these findings, it becomes readily apparent that not being able to tolerate negative emotions results in significant impairment.
So why would low distress tolerance motivate somebody to engage in such harmful behaviors?  The answer is similar to the information we discussed in a prior article on the functional model of NSSI.  When we hit a particular threshold of feeling upset, our priorities become almost entirely focused on immediately reducing our distress.  For most of us, this threshold is quite high - it takes a lot for us to act in a way that completely disregards potential long-term consequences.  When an individual has low distress tolerance, however, it takes less stress for them to reach their threshold - there is already more water in their glass.  There is compelling evidence that, if we believe a behavior has the ability to reduce our feelings of negative affect, we are more likely to engage in that behavior, even if it is unhealthy, (e.g., binge eating; Fischer & Smith, 2008).  There is also compelling evidence that some unhealthy behaviors have the ability to quickly reduce negative emotions (Smyth et al., 2008).  This is unfortunate because, as an individual learns that a behavior can quickly reduce feelings of negative affect, they become more likely to do it again the next time they reach that threshold.  If the threshold is low, they can quickly get stuck in a viscious cycle.
    Fortunately, researchers have developed empirically supported treatments that directly address distress tolerance.  Dialectical behavior therapy (DBT; Linehan, 1993a; Linehan, 1993b) is a form of cognitive behavioral therapy (CBT) that was originally designed to treat borderline personality disorder (BPD), which is characterized by highly labile emotions, difficulties regulating behavior when upset, stormy interpersonal relationships, and self-injury.  Several studies have indicated that DBT is an effective treatment for BPD (e.g., Linehan, 1998), which is an important and often misunderstood fact due to some particularly harmful and prevalent misinformation about that disorder.  DBT, which we will describe in more detail in future articles, includes a module that focuses entirely on teaching clients distress tolerance skills, ways to weather the storm when no healthy behavior is capable of changing the way they feel in that moment.  Such skills include radical acceptance - a skill that teaches individuals to shift their focus from the way they wish things were to the way they actually are, accepting reality and devising plans to attain the best possible outcome given their circumstances.  Recently, several researchers have demonstrated that DBT has empirical support as a treatment for both bulimia nervosa and binge eating disorder (Safer, Lock, & Coutourier, 2007; Safer, Telch, & Agras, 2001; Telch, Agras, & Linehan, 2001).  More work needs to be done to demonstrate that DBT is an effective treatment for individuals whose distress tolerance has resulted in substace abuse or other problems; however, an important consideration to keep in mind is that such individuals may also meet criteria for BPD, bulimia, or binge eating disorder and thus benefit from DBT.
    Ultimately, it appears that low levels of distress tolerance can be highly dangerous, in that they are correlated with an increased use of harmful behaviors, but that distress tolerance is a good target for therapeutic interventions.  By understanding the mechanisms behind behaviors, whether this means distress tolerance, affective lability, or some other variable, researchers can be better equipped to design and test treatment protocols that have a greater likelihood of reducing rates of harmful behaviors.  Additionally, by understanding such mechanisms, it becomes clear how behaviors that might seem unrelated, such as binge eating, NSSI, and substance abuse, actually share important risk factors and, as such might respond to similar treatments.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Transdiagnostic CBT for Eating Disorders - Enhancing CBT?

by Joye C. Anestis, M.S.

The DSM-IV features 3 eating disorder (ED) diagnoses, anorexia nervosa and bulimia nervosa, by far the most well-known, and eating disorder not otherwise specified (EDNOS), the most prevalent of the ED diagnoses.  Ironically, while EDNOS is the most diagnosed ED, treatment research has often neglected this population, focusing mostly on anorexia and bulimia.  We know that CBT is the "gold standard" treatment for bulimia, but we don't know if this treatment is equally effective for the EDNOS population.  Christopher Fairburn and his colleagues have attempted to remediate this problem by revising traditional CBT for bulimia into a transdiagnostic approach for all three EDs.  A new study published in the American Journal of Psychiatry features a randomized control trial of this new treatment. 

Fairburn et al. describe transdiagnostic CBT as an "enhanced" version of CBT that features 2 versions of the treatment: a "focused" form which focuses exclusively on the eating disorder and a "broad" form which addresses some of the other issues commonly found in eating disordered patients (e.g., self-esteem, perfectionism, interpersonal problems, mood intolerance).  This was a well-conducted RCT of the two treatments - the sample was primarily female, participants with BMI < 17.5 were excluded - so only participants with bulimia (38.3%) & EDNOS (61.7%) remained. The results indicate that the two versions of the CBT were overall equally effective, regardless of diagnosis.  So this is a novel finding for the treatment of EDNOS!  The authors also suggest that the "focused" form of the treatment should be the "go-to" treatment for most clients, and the "broad" form should be used with client who have additional psychopathology that warrants treatment of the domains it addresses.

This was my first encounter with Fairburn's transdiagnostic CBT, and the article doesn't give very much detail about it.  I am curious about how different the "focused" version of the treatment is from the traditional CBT for bulimia.  I also wonder how different the domains covered in the "broad" transdiagnostic CBT are from the domains covered in dialectical behavior therapy (which also is successful in the treatment of bulimia).  Finally, the authors didn't give a rationale for excluding folks with anorexia - I wonder how they would have responded (although my hunch is that they would not have displayed a treatment effect, as CBT is not the treatment of choice for anorexia).What do you think?  Has anyone had experience with this enhanced CBT?  Do you have other questions about the study?

To learn more about this treatment, please see Cognitive Behavior Therapy and Eating Disorders by Christopher Fairburn.