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Alice is a 31-year-old woman who works as a customer service representative for a large corporation. She initially presents to her family physician with depressed mood following the break-up of her most recent relationship — a man who turned out to be alcoholic. With a great deal of embarrassment, she reveals that she’s had a habit of binge eating alone at night for the last two years. She favours sweets for this, often consuming a whole box of cookies in one shot. She denies any purging-type behaviour such as induced vomiting, or laxative or diuretic abuse. Her weight has been increasing and she’s gained some 12 kilograms in the last year.
Alice was the youngest daughter of a professional couple. Her older sister had been a high-achieving, competitive athlete; her mother — a very successful lawyer — created a family life that emphasized control and often compared her two daughters with one another as well as with other high-achieving children. Alice was not very athletic, but was gifted musically. She’d done well in university, although a lack of confidence had hampered her in the business world, where she felt ashamed and disappointed in her career. Her binge-eating symptom arose in this context, and was further complicated by an unsuccessful romance with a young lawyer. Alice didn’t want treatment with medication but was interested in receiving help, specifically with her binge eating.
Binge eating (in DSM IV — Eating Disorder Not Otherwise Specified) is the most common eating disorder encountered in clinical practice. A new study by researchers in Oxford, UK, compared two forms of cognitive behavioural treatment (CBT) for eating disorder and found encouraging responsiveness to treatment (Am J of Psychiatry published online Dec. 15, 2008). CBT-Ef focused on eating disorder concerns such as:
- preoccupation with weight and shape
- extreme dieting
- binge eating
- purging.
Another form of therapy, CBT-Eb, also addressed the broader issues:
- perfectionism
- low self-esteem
- mood intolerance
- interpersonal difficulties.
One hundred and fifty-four patients were studied, all with a DSM IV eating disorder diagnosis — anorexia was excluded. Patients received 20 weeks of therapy with a follow-up at 60 weeks — an unusually long follow-up. Participants were randomized to treatment or an 8-week waiting list. The therapies were the same for the first 4 weeks, and then differentiated.
Impressive results
The results? Patients on the waiting list experienced little change in their symptoms. Both treatment groups, however, showed significant diminishment of symptoms, to within a standard deviation of community norms. These changes persisted at the 60-week mark:
- 61% of patients with bulimia, and
- 45.7% of those with a non-specified eating disorder
maintained their initial gains — an impressive result. The more complex form of therapy (CBT-Eb) had slightly better success with patients who had other substantial psychological problems accompanying their eating disorder. The more focused eating disorder therapy (CBT-Ef) had better results for those who did not. This study is significant in including typical patients seen in non-specialized practice. It also clearly shows that focused treatment can be quite effective, with lasting effects.
Alice’s treatment
This specific treatment was not available to Alice, but she initially had a course of CBT focused on her eating behaviour, which helped her to get control of the binge eating. She then began to perceive the underlying issues in her life:
- a vulnerability that often led to the collapse of her self esteem
- a proneness to shame, which had led her to tolerate a destructive relationship for too long.
She started to understand how her powerful wishes to win her mother’s favour — and at the same time to defeat her mother’s hopes for her — remained dominant forces in her emotional life that interfered with the ability to lead a satisfying adulthood. She was encouraged to explore these issues further in psychodynamic therapy.
Unlike in Freud’s day, when guilt-ridden personalities were very common, we now see many more people whose characters are organized around narcissistically driven demands for perfection, which can give rise to compulsive-driven behaviours such as binge eating and other eating disorders.
Barry L. Gilbert, MD, CCFP, FRCPC is a psychiatrist, psychoanalyst and Assistant Professor of Psychiatry at the University of Toronto.
