Psychosomatics 50:182-183, March-April 2009
doi: 10.1176/appi.psy.50.2.182
© 2009 Academy of Psychosomatic Medicine
Binge-Eating Disorders: Clinical Foundations and Treatment
By James E. Mitchell, Michael J. Devlin, Martina de Zwaan, et al., New York, Guilford, 2008, 214 pages, ISBN 13: 978-1-59385-594-9; ISBN 10: 1-59385-594-X, $30.00
Natalia Ortiz, M.D.
This interesting and easy-to-read book portrays the discussion of binge-eating disorders from both a theoretical and a practical, clinical approach. The book is divided into two parts: "What We Know About Binge-Eating Disorder and Its Treatment," and "A Cognitive-Behavioral Treatment Program for Binge-Eating Disorder."
The first part walks one through a comprehensive review of binge-eating disorders. It discusses the diagnosis, epidemiology, clinical features, course of illness, psychopathology, and pathophysiology, using a biopsychosocial model. Special attention is given to the definitions of different eating habits and how subjective they can be. Within this review, the authors formulate a relationship between obesity and binge-eating disorders. Well presented is the fact that obesity is a complex health problem that cannot solely be explained by the binge-eating behaviors. Comparisons are made between obese patients with and without binge-eating disorders.
After helping the reader understand the behaviors and how they can be explained biologically, psychologically, and socially, the authors emphasize the medical complications that are seen in patients with eating disorders. I agree with this emphasis because it is important to have a clear understanding of the medical complications, so the physician may educate patients about this aspect in order to engage them in seeking treatment. A comprehensive range of treatment options, from psychotherapy and pharmacotherapy to invasive procedures, including bariatric surgery, are then presented. Different procedures and their impact on behavior from a metabolic-physiologic point of view are explained.
The second part is in a workshop format. It takes the form of a manual that guides the practitioner through the steps of diagnosis and treatment based on cognitive-behavioral techniques. This model has been actively studied in two randomized trials, one at the University of Minnesota and the other at the Neuropsychiatric Research Institute in Fargo, North Dakota.
The guide consists of two parts that are intertwined. It includes a basic explanation about the theory behind cognitive-behavioral therapy and its application to the understanding of eating-disordered behavior in these patients. It describes how the patients’ thoughts can be reconstructed to modify behaviors to achieve a desirable outcome. The treatment model consists of 15 sessions, each lasting 45 minutes, over a period of 15 weeks. Each therapy session is designed to cover specific objectives, and a handout is provided that includes psychoeducation and a worksheet to help patients explore and work on their treatment.
The first session consists of the evaluation and monitoring of binge episodes, including identification of cues. The goal is to help the patient demonstrate commitment by describing and balancing the reasons to stop or continue the binging, as well as listing alternatives to it. A deeper exploration of the cues and their consequences set the goals of the second session. Integrated within this session are methods for rearranging the approach and responses to the identified cues. The reorganization of new behaviors is supported by the exploration of positive rewards.
The discussion of the relationship between binge eating preceded by fasting is described in Session 3. The patient is advised to explore thoughts related to food and to monitor food intake in a daily basis. The introduction of the use of an exercise program and its benefits are discussed. The next three sessions include a systematic exploration of the cues leading to thoughts, feelings, and behaviors that perpetuate binge-eating behaviors. An examination of the associated cognitive misinterpretations and how to restructure them is provided.
In Session 7, the connection between impulsivity and self-control is explored. Strategies to enhance self-control are taught, for example, through relaxation techniques. The work needed to improve mood and self-esteem is described, to nurture the "dry soul" of the binge eater. The latter is explored further in Sessions 10 and 12. The relationship between healthy eating and exercising is discussed in greater depth in Session 13. Disturbed body-image is the focus of Sessions 8 and 9. The influence of family and culture in the perpetuation of the distortion of body-image is described, along with the behavioral techniques that are useful in modifying it. Modifications that can empower the patient in problem-solving and stress-management are suggested in Session 11. Sessions 14 and 15 integrate the techniques learned in the earlier sessions, and the emphasis is shifted to the goal of avoiding relapse and promoting maintenance.
I enjoyed the book, and I recommend it. It is a comprehensive but concise review of the literature on the binge-eating disorders. It is very practical to follow the manual and integrate it into the treatment of affected patients. The book explores a group of disorders in psychiatry that are very important to identify and treat because of their possible severe medical consequences. It is definitely a subject that has to be mastered by practitioners of psychosomatic medicine, as well as those in primary care.
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FOOTNOTES
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Dr. Ortiz is Assistant Professor of Psychiatry in the Division of Consultation–Liaison Psychiatry at Temple University School of Medicine in Philadelphia, PA.
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