Senior Project Final

Literature Review on Mindfulness Cognitive Behavioral Therapy Treatment for

Binge-Eating Disorder

Kyra Benson

December 2014

Concordia College-Moorhead, Mn

Mindfulness Treatment for Binge-Eating Disorder

Introduction

There are a variety of eating disorders that range from an individual

restricting his or her diet in order to lose weight (Anorexia Nervosa) to an

individual eating a large amount of food in one sitting (Bulimia Nervosa or Binge-

Eating disorder). Each disorder has different symptoms and different concerns to

be addressed in diagnosis and treatment. This literature review will first discuss

how Binge-Eating disorder is different from other eating disorders, then it will

examine why Cognitive Behavioral Therapy is an effective form of treatment for

eating disorders. Then the Mindfulness treatment that exists within Cognitive

Behavioral Therapy, is examined in how it is used to treat not only the symptoms

of Binge-Eating Disorder but also examining the thinking patterns that underlie

the disorder. This Mindfulness treatment is also compared to the Dialectical

Therapy Treatment, which will be used as a form of comparison

Background

General Eating Disorders

According to the Diagnostic and Statistical Manual of Mental Disorders

(DSM)(2013) eating behavior patterns are characterized as an eating disorder if

the eating behavior alters the amount of food consumed or the manner in which

food would be consumed. This behavior must also significantly impair health and

functioning of the individual. There are many different types of eating disorders

but the most common ones are Anorexia Nervosa, Bulimia Nervosa, and Binge-

eating disorder. In previous versions of the DSM there were three categories:

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Anorexia Nervosa, Bulimia Nervosa, Eating Disorder Not Otherwise Specified

(NOS). But in the DSM-V, Binge-eating disorder was added as a separate

category. This allows for research to be done not only in the diagnosis for Binge-

eating but also in the treatments that are available.

In order to be categorized as suffering from Anorexia Nervosa an

individual must be restricting the amount of food being consumed which leads to

extreme weight loss. The other key symptom of Anorexia is the distortion in the

perception of his or her own body (i.e., the individual is unable to see the degree

of weight loss) (DSM-V, 2013). According to the Anorexia Nervosa entry in the

Gale encyclopedia of Mental Health, Anorexia Nervosa is most common for

women in their late teens and is characterized by the fear of gaining weight,

which can lead to extreme weight loss and malnourishment.

Another type of eating disorder, known as Bulimia Nervosa is

characterized by the following set of criteria. Individual suffering from Bulimia

Nervosa, experiences reoccurring episodes which consists of eating an unusually

large amount of food in a short amount of time accompanied by lack of feeling in

control of behavior during this time. This reoccurring inappropriate behaviors to

compensate for weight gain (self-induced vomiting, use of laxatives etc.), and the

behavior occurs at least once a week for duration of three months. This disorder,

like Anorexia Nervosa, affects mainly women in their late teens. Bulimia Nervosa

is characterized by compulsive overeating followed by purging (Fundukian 2008).

Information on Binge-eating Disorder

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According to Tanofsky-Kraff et. al (2013), Binge-Eating Disorder is

defined as a serious eating disorder (often referred to as overeating) that is

characterized by frequent consumption of a large amount of food over a limited

period of time. This differs from Anorexia Nervosa in the fact that the individual is

not restricting the amount of food they intake. It is also different from Bulimia

Nervosa. Although both disorders include the overconsumption of food in a small

amount of time, Binge-Eating Disorder does not include purging or other attempts

to compensate for the increase in caloric intake. However some individuals

suffering from Binge-eating disorder do attempt to diet in between binge-eating

episodes. Unlike Anorexia Nervosa and Bulimia Nervosa, Binge-Eating Disorder

affects both women and men (although it is more common among women). This

disorder typically begins in late adolescence but also occurs into middle

adulthood. Binge-eating disorder is different from other abnormal eating patterns

such as continuous snacking, since these individual suffering from Binge-Eating

Disorder overeat in the absence of hunger.

The following consists of the general characteristics of Binge-Eating

Disorder. The defining characteristic of Binge-Eating Disorder is the loss of

feeling in control of their eating habits (Tanofsky-Kraff et. al, 2013). According to

the Diagnostic and Statistical Manual of Mental Disorders (2013) there are set of

specific characteristics that all must be met in order for the pattern of eating

behavior to be classified as Binge-Eating Disorder. One of these characteristics

is the reoccurrence of binge-eating episodes. An episode consists of eating what

would be considered a larger amount than most people would eat in a short

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amount of time, combined with a lack of control over their eating habits during

that time. Also within these episodes three of the following five characteristics be

must associated with the episode: eating more quickly than normal, eating until

feeling uncomfortably full, eating large amounts of food when not feeling hungry,

eating alone because of embarrassment, feeling disgusted, depressed or guilty

afterwards. There also must be a feeling of distress over their binge-eating

behavior. Finally the binge-eating behavior must occur at minimum once a week

for three months. Binge-Eating behavior is not being associated with

inappropriate compensatory behaviors, such as with bulimia and does not occur

in the course of Anorexia Nervosa or Bulimia Nervosa (DSM-V, 2013).

In addition to all these criteria, there are also criteria for the severity of the

Binge-Eating Disorder. The following are the classifications for severity: mild

consists of 1-3 binge-eating episodes per week, moderate consists of 4-7 binge-

eating episodes per week, severe consists of 8-13 binge-eating episodes per

week, and 14 or more binge-eating episodes per week results in being classified

as extreme (DSM-V, 2013).

According to Tanofsky-Kraff et. al (2013) the issue of the symptoms of

Binge-Eating Disorder are often hard to classify since the maladaptive behavior

typically takes place when the individual is alone. However here are some of the

symptoms of Binge-Eating Disorder: feeling out of control when eating, not being

able to stop eating once they have started, continuing to eat after feeling full,

eating large amounts (sometimes as much as 10,000 calories), eating very

quickly and alone or in secret, hoarding food, dieting without weight-loss,

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obsession with body weight, depression or anxiety, and substance abuse. As can

be seen from the list, those people close to the individual with binge-eating

disorder easily overlook many of these. This is one of the challenges that exist to

diagnosing and treating this disorder (Tanofsky-Kraff et. al , 2013).

In addition to having difficulties identifying those suffering from this

disorder, there are also problems when it comes to identifying the etiology.

Tanofsky-Kraff et. al (2013) discussed the following causes associated with

Binge-Eating Disorder. There seems to be a genetic disposition towards Binge-

Eating Disorder. In addition to hereditary factors, other risk factors include:

frequent dieting or frequent weight fluctuation, poor impulse control, difficulty

expressing emotions, and low self-esteem. Whatever the contributing factors

may be Binge-eating disorder seems to be a coping mechanism, because it

temporarily alleviates uncomfortable feelings. The behavior itself often leads to

more negative feelings, which perpetuates the cycle (Tanofsky-Kraff et. al, 2013).

These are the symptoms and concerns to be addressed when treating Binge-

Eating Disorder, next the treatment of Binge-Eating Disorder will be discussed.

Background on Cognitive Behavioral Therapy

According to Ivey and Andrea (2012), Cognitive Behavioral Therapy is

often an effective form of treatment for maladaptive behavior because it involves

the alteration of behaviors as well as cognition. Cognitive Behavioral Therapy is

the hybrid of cognitive therapy and behavior modification therapy. Cognitive

Therapy focuses on the idea that anxiety results from patterns of thinking and to

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address this anxiety the patterns of thought must be addressed. Behavioral

modification therapy focuses on changing the behavior through direct

observation. In these two disciplines one focuses exclusively on cognition and

the other focuses exclusively on behavior, with no intersection existing between

the two. The reason that Cognitive Behavioral Therapy is so effective is that it

combines the two approaches. When examining eating disorders, not only is the

behavior damaging to the individual but also the thoughts that are causing the

behavior (Ivey and Andrea, 2012).

CREATE TRANSITION

Background on Mindfulness

According to an article on Dialectical Behavior Therapy for Binge-Eating

Disorder (1999), Binge eating is used as a means to avoid the awareness of

painful emotions. Mindfulness meditation is a means to teach awareness of

emotions and bodily sensations. What makes this different from other awareness

treatments is the idea that is awareness of the particular moment and

acknowledging the sensations without passing judgment on them. It is a

paradoxical observation because even though the individual is bringing

awareness to the experience, they are viewing in a non-judgmental way. This is

particularly important because the use of the technique of mindfulness is

designed to reduce emotional response such as shame and guilt, which are so

prevalent in Binge-Eating Disorder. This is due to the fact that once negative

emotions has been triggered, the binge eating behavior is utilized as means to

distract themselves from the uncomfortable emotions (Wiser 1999).

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Binge-Eating Disorder Treatment Evaluation

Mindfulness Treatment

Average Population Participants

In a study done by Smith (2006), used average population

participants recruited 25 adult men and women at the University of New Mexico

for an 8-week mindfulness program. The course was advertised as Mindfulness

Based Stress Reduction program with no mention of any emphasis on binge-

eating behavior in the advertisement. This study used MBSR as a starting point

for the purpose of the study. This study followed the Mindfulness Based Stress-

Reduction (MBSR) course: 3 hour-long weekly group session where the aim was

to increase mindfulness through techniques such as breathing, meditation, Hatha

yoga and group discussion as well as tasks to practice at home. This program

(different from MBSR) also had a component focusing on eating mindfully,

progressing from snacks to meals. The program was evaluated through a

questionnaire before and after the course. In addition to that multiple measures

were used including Binge eating to rate the severity of those behaviors. The

results demonstrated that for those participants with binge-eating behaviors the

program significantly decreased the behavior (consistent across all severity

levels) (Smith, 2006).

This study is a good introduction to mindfulness as a treatment for Binge-

Eating Disorder. It established that mindfulness when directed to behaviors

towards food decreases the binge eating behaviors. This relationship was

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established through the use of volunteers who were unaware that this was the

focus of the program. To improve on this study, a program that focuses on

mindfulness and disordered eating behavior should be done with participants that

are knowledgeable on the intent of the study to determine the applicable effect of

this treatment.

In another study done by Masuda (2010) using the general population

focused on Mindfulness as means of mediating the relationship between the

cognition patterns behind disordered eating patterns and psychological distress.

The participants were recruited from undergraduate psychology classes and

asked to complete a survey. The survey in this study utilized three measures to

assess disordered eating. The disordered eating-related cognitions measure

consisted of a 24-item self-report questionnaire that evaluated the distorted

cognitions related to eating disorders. This was measured on a 5-point Likert

scale and addressed issues such as the fear of weight gain, the need to be thin

or attractive in order to be socially accepted, self-esteem based on weight gain,

and controlled eating habits. The measure of mindfulness was assessed using a

15-item questionnaire using a 6-point Likert scale to evaluate the frequency of

mindlessness in daily behaviors. The measure of general psychological ill health

used a 10-item questionnaire using a 4-point Likert scale, where the participants

were asked to rate frequency of stressor. The final measure that was used was

the Emotional Distress in stressful interpersonal and emergency situations, which

was evaluated on a five-point scale. The results of this study demonstrated that

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the lack of mindfulness was an important predictor for general psychological ill

health and emotional distress (Masuda, 2010).

This study is a good starting point for the research of mindfulness as

therapeutic treatment. They established that there is a relationship between the

lack of mindfulness (mindlessness) and poor psychological health as well as

emotional distress. This is an important connection to make following the

previous study, since this type of treatment not only affects the disorder eating

behaviors themselves but also psychological health in general. A weakness of

this study is that although the researchers determined that there is a relationship

between these variables, they did not evaluate what type of relationship or the

strength of the relationship. Also the researchers evaluated the lack of

mindfulness but did not evaluate mindfulness itself. This is a good preliminary

study to initiate this area of research but does not carry much significance other

than that.

Obese/Overweight Participants

A study done by Kristeller (1999) 21 women responded to an

advertisement for women struggling with their weight and Binge-Eating. These

women met the criteria for diagnosis of Binge-Eating Disorder but were not

currently in weight loss program or psychotherapy that would interfere with

results of this study. These women were diagnosed by professionals that were

part of the research team prior to the start of the study. Seven sessions were

conducted over a 6-week period, where the primary focus was utilizing

mindfulness meditation in the following ways: general mindfulness meditation,

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eating meditation, and mini-meditation. General mediation focuses attention,

taking note of thoughts, emotions and being aware of bodily sensations. Eating

meditations applies this specifically to thoughts and emotions related to food,

where as mini-meditations are to take a few moments and become aware of

thoughts and feelings. As a result of this study, both the number of binges per

week as well as the Binge-Eating scores dropped significantly, but no overall

change in weight (Kristeller, 1999).

If evaluating this study as a weight loss treatment, it would be seen as

ineffective since there was no overall change in weight. However it was one of

the first treatments that attempted to adapt Mindfulness-based techniques in a

program that was specifically designed for weight loss. This is a shortcoming of

many treatments for binge-eating disorder. However if this study were evaluated

for the reduction of binge-eating behaviors, it would be seen as effective. Not

only did the binge eating behaviors decrease, there was a significant increase in

feeling of control over eating (which is one of the major symptoms of Binge-

Eating Disorder) as well as awareness of hunger cues. A weakness of this study

is the restrictive sample: small number of only women with ages or history of

binge eating behavior not addressed.

In a study done by Tapper (2009) 62 women who were trying to lose

weight joined a program that utilized mindfulness-based weight loss intervention

as part of the weight loss program. In addition to weekly meetings with a dietitian

and exercising, participants attended three separate one and a half hour

mindfulness workshops, where they were given things to practice between the

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sessions. This was the experimental group. The control group only had the

dietitian consultations and exercise. The study was evaluated through the use of

the body mass index scale as well as several disordered eating behavior scales,

including the Binge-Eating scale. The results showed that participants who were

in the group attending the mindfulness workshop had greater decreases in body

mass index and binge eating scale scores (Tapper, 2009).

This study used mindfulness as an aspect of the treatment, but it was not

the main focus of the treatment. As mentioned previously, in many of the other

studies looking at weight loss and the use of Mindfulness, the use of Mindfulness

typically does not result in weight loss. However in this study, the reduction of the

body mass index score is most likely a result of the combination of the

mindfulness technique and the change in diet and exercise. But they do not

make clear which effects were results of the diet and exercise changes and

which were due to the mindfulness intervention. Although they did state that the

decrease on the Binge Eating Scale was due to the mindfulness intervention.

However the combination of these treatments makes it difficult to determine

which was the cause of the effects of the treatment.

Participants with eating disorders

A study done by Leahy (2008), looked at the mindfulness technique

in a group therapy context. The participants were 7 individuals who had just

received weight reduction surgery and were having difficulty regulating their

eating behaviors after the surgery. The treatment consisted of the following four

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stages. The first stage consisted of psychoeducation, enhancing motivation,

begin regular self-monitoring, development of insight into eating triggers. The

next stage focused on giving group member 5-6 small meals per days, controlling

portions as well as external triggers, not drinking or engaging in other behaviors

while eating. The focus of the third stage was to change problematic thought

processes, increase mindfulness practices, and improve coping skills. The last

stage focused on solidifying newly learned behaviors and ways of thinking, as

well as mindfulness techniques and emotion regulation strategies. The results of

this study showed significant improvement in binge eating behaviors (Leahey,

2008).

This was a very thorough and detailed study. The researchers very clearly

laid out what was to be accomplished in each stage and how that was to be

achieved. They said that there was significant improvement shown but not more

than that and not many details were included. Also in their study they did not

address how this study could be applied to other areas. This would be a tricky

study to apply to other areas because of the sample that was used in this study.

A study done by Alberts (2012) focused on using the mindfulness

technique to address and reduce the problematic eating behaviors. In this study

they focused on three disordered types of eating behaviors: restrained, emotional

and external eating. Restrained is restricting the amount of food consumed.

Emotional and external eating is engaging in eating behaviors in response to

external cues instead internal cues such as hunger.

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Participants were recruited through advertising for individuals with

problematic eating behaviors, who were then asked to answer a variety of

questionnaires before and after treatment including the following: Kentucky

Inventory Mindfulness Skills Extended (used to measure the change mindfulness

skill) Dutch Eating Behaviour Questionnaire, Body Shape Questionnaire (Alberts

2012).

The treatment plan consisted of five main concepts. One was the use of

mindful eating where the awareness is focused on sensations such as taste.

Another concept that was used was the awareness of physical sensations such

as hunger. There was also inclusion awareness of thoughts and feelings related

to hunger. Acceptance and lack of judgment of sensations, thoughts, feelings

and body was also emphasized. The final concept focused on in this study was

the awareness as well as progressive steps to change daily patterns of eating.

The results of the study demonstrated that the participants in the mindfulness

conditions showed significantly greater decreases on measures of food cravings,

concern over body image, as well as emotional and external eating than those

participants who were not in the condition (Alberts, 2012).

This study focused on aspects that were not the reduction of the specific

disordered eating behavior. Instead this study focused on what effect the

mindfulness treatment had on the underlying causes of eating disorders. This is a

much more effective form of treatment when you can address the cause of the

behaviors as opposed to only addressing the behaviors. This study, as opposed

to the previous study, was very clear in the outcomes of their study. One issue

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with this study is the fact that they don’t address the gender of the participants. It

is support that the majority of individuals suffering from eating disorders or those

types of behavior are women, but that doesn’t mean that men don’t suffer from it

as well.

A study done by Butryn (2013) focused on the relationship that

mindfulness has with eating disorder symptomatology, as well as how changes in

mindfulness effects changes in it. This study looked specifically at women who

are receiving residential treatment. Eighty-eight women participants, who were

currently admitted to two specific residential treatment facilities for eating

disorders participated in this study (the names of the facilities were not included

in the published research study). Measures of mindfulness and symptomatology

of eating disorders were administered before admission and after being

discharged from the facility. The results of this study demonstrated that as

mindfulness improved, so did the symptomatology (Butryn, 2013).

This study was very beneficial in the fact that it measured the effect of

mindfulness while the participants were being treated in a residential facility. This

demonstrates the effectiveness of the mindfulness technique in controlled

treatment environments. Whereas most other research has focused on the

Mindfulness technique in situations where the individuals come and get the

training and then go home. A weakness of this study is that they simply

measured before admission to the facility and after being discharged from the

facility but provided no information on how the mindfulness technique was

implemented.

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Dialectical Behavior Treatment

The previous studies have all examined the mindfulness treatment in

addressing either Binge-eating disorder or the causes behind the binge eating

behaviors. This next section looks at how the Dialectical Behavior Therapy

treatment compares to the Mindfulness Treatment.

In a study done by Telch (2001) looked at dialectical behavioral

therapy for Binge-Eating Disorder. This study had 44 female participants that met

the full diagnostic criteria for Binge-eating disorder (but also could not be

involved in any psychotherapy or weight loss treatment), and enrolled in program

after seeing advertisement for free treatment through a Stanford University

research study. The participants were assessed both before started treatment

and after completing 20 weeks of treatment. They were assessed through

structured interviews, questionnaires, and measurements of height and weight.

The treatment consisted of 2-hour long weekly session for 20 weeks in which the

therapist focused on mindfulness skills, emotion regulation skills, and distress

tolerance skills. By the end of the treatment 89% of women had stopped binge-

eating behaviors, but only 56% were still abstaining from these behaviors 6

months after treatment had finished (Telch, 2001).

Overall this study was very effective. The researchers focused on one

disorder and one treatment, going into detail describing treatment and results.

These One weakness that this study had is that since the participants are all

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women it may be difficult to generalize. Also the fact that they did not differentiate

the age groups could contribute to that.

A study by Klein (2013), they compared the use and effective of diary

cards for individuals’ self-monitoring with group dialectical behavioral therapy.

Dialectical behavior therapy is a branch of cognitive behavioral therapy. For

dialectical behavior therapy the focus is to help individuals change ineffective

patterns of behavior. The participants were those interested in this program as

advertised and were diagnosed with either Binge-eating disorder or Bulimia

Nervosa. In one condition these participants were asked to attend 15 two and a

half hour group dialectical behavioral therapy sessions and asked to watch

videotapes of any sessions that they missed. Participants in the other condition

were given a chart of skills and asked to keep track of which days they worked

on which skills. For both the diary card and the group dialectical behavioral

therapy, the results showed an improvement in binge-eating behaviors, but the

retention rate was higher for the dairy card technique.

In this study it was not defined what dialectical behavioral therapy was and

how it was different from cognitive behavioral therapy. Also, when the

researchers were describing the two conditions, they were very specific with the

diary cards (even gave us an example card). In the dialectical therapy, however,

the description was quite vague. The length of the treatment was described but

the specifics of the treatment were not. The background section was very

detailed and they made sure to address the implications of their study. This study

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also addressed not only the disorders themselves but the underlying causes as

well.

Conclusion

As demonstrated through the studies evaluated above, the mindfulness

technique of Cognitive Behavioral Therapy can be used in many ways and in

many contexts with Binge-Eating Disorder. But this technique seems to be the

most effective when it involves a detailed program, with concrete actions to

perform in addition to the cognitive aspect. Although this technique is initially

effective, over time (and in the case of one study in a time as short as 6 months

effectiveness was almost halved) the benefits of this technique can diminish or

disappear. That is why the aspect of this technique where the individuals are

given the tools to succeed is so important

One of the important concepts of the mindfulness technique is that the

reduction of the behaviors of the Binge-Eating Disorder does not necessarily

mean weight loss. The goal of the mindfulness technique is to remove the

underlying issues that become obstacles to normal eating behaviors. So in order

for the mindfulness technique to be seen as effective, the improvement of the

binge eating behaviors is necessary but weight loss is not.

This treatment needs little additional research. It has demonstrated to be

an effective treatment in a variety of contexts, for both binge eating behaviors

and the causes that underlie those behaviors. This technique needs to be put

into practice. I propose a group therapy program (within groups it when this

technique seems to be most effective) that has a progressive program of skills

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that are taught in weekly sessions so that eventually the individual can use these

skills without the aid of the group. However part of this program should a monthly

individual appointment to check in on the progress. This is essential because

without the encouragement and upkeep of the skills learned through the

Mindfulness treatment the effects of the treatment diminish rapidly.

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References

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Baer, R., Fischer, S., & Huss, D. (n.d.). Mindfulness-based CognitiveTherapy Applied To Binge Eating: A Case Study. Cognitive andBehavioral Practice, 351-358.

Butryn, M. L., Juarascio, A., Shaw, J., Kerrigan, S., Clark, V.,O'Planick, A., & Forman, E. (2013). Mindfulness and itsrelationship with eating disorders symptomatology in womenreceiving residential treatment. Eating Behaviors, 14, 13-16.

Courbasson, C.M., Nishikawa, Y., & Shapira, L.B. (2011). Mindfulness-ActionBased Cognitive Behavioral Therapy for Concurrent Binge-Eating Disorderand Substance Use Disorders. Eating Disorders, 19(1), 17-33.

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Kristeller, J., & Hallett, C. (1999). An Exploratory Study Of AMeditation-based Intervention For Binge EatingDisorder. Journal of Health Psychology, 357-363.

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Masuda, A. (2010). Mindfulness mediates the relation between disordered eating-related cognitions and psychological distress. Eating Behaviors, 11, 293-296.

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Smith, B. W., Shelley, B. M., Leahigh, L., & Vanleit, B. (2006). A Preliminary Study of the Effects of a Modified Mindfulness Intervention on Binge Eating. Complementary Health Practice Review, 11(3), 133-143.

Tanofsky-Kraff, M., Bulik, C.M., Marcus, MD., Striegel, R.H., Wifley, D.E., Wonderlich, S.A., & Hudson, J.I. (2013). Binge eating disorder: The next generation of research. International Journal of Eating Disorders. 46(3). 197-207

Tapper, K., Shaw, C., Ilsley, J., Hill, A. J., Bond, F. W., & Moore, L. (2009). Exploratory randomised controlled trial of a mindfulness-based weight loss intervention for women. Appetite, 52, 396-404.

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Vocks,S., Tuschen-Caffier, B., Pietrowsky, R., Rustenbach, S.J., Kersting A., & Herpetz, S. (2010). Meta-analysis of the effectiveness of psychological and pharmacological treatments for binge eating disorder. International Journal Of Eating Disorders 43 (3). 205-217.

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binge-eating disorder. In Session: Psychotherapy inPractice, 55(6), 755-768.

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