Areas of Expertise: Binge-Eating Disorder

Eating disorders include binge-eating disorder, bulimia nervosa, anorexia nervosa and eating disorder not otherwise specified. These eating disorders can be reliably diagnosed during the first diagnostic session, and are among the ten leading causes of disability among young women.

What is Binge-Eating Disorder?

Binge-eating disorder is defined by recurrent episodes of binge eating and associated distress in the absence of regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa. Nearly 60% of clients with eating disorders fall in this third, unspecified category reserved for those individuals who have a clinically significant eating disorder that does not meet the criteria for anorexia nervosa or bulimia nervosa.

What is Bulimia Nervosa?

Bulimia nervosa is characterized by binge eating and compensatory behaviors such as vomiting and fasting occurring an average of twice per week for three months, and a self-concept dominated by shape and weight. Bulimia nervosa is divided into two subtypes: a non-purging subtype characterized by fasting or exercise after binge eating, and a purging subtype characterized by the use of self-induced vomiting, laxatives or diuretics after binge eating.

Prevalence of bulimia nervosa in the general population is roughly 1-2%. Estimates of remission over time range from 31% to 74%. During the early stages of treatment, relapse is common, so clients are encouraged to adopt a "one day at a time" approach to recovery.

What are the medical complications?

Medical complications from binge-purge behavior include possible injuries to the esophagus, stomach, intestines, skin and teeth; and lung, kidney and heart complications. Misuse of laxatives may lead to dehydration, upset the body's mineral balance, burn out the colon, and damage the digestive tract lining. Serious medical complications also arise from misuse of diuretics, Ipecac syrup, diet pills and fad diets.

What is Anorexia Nervosa?

Anorexia nervosa comprises four specific criteria: marked weight loss, fear of gaining weight, body image distortion, and in females, amenorrhea. Like bulimia nervosa, it is divided into two subcategories: a restricting subtype for those who restrict food intake and exercise for weight control, and a binge-purge subtype for those who engage in binge eating and or purging. Anorexia nervosa involves the pursuit of thinness through dietary restriction and other measures, resulting in body weight below the normal range. Body Mass Index (BMI) is less than 17.5. A person with anorexia nervosa may starve to dangerous levels, at least 15% below what would be considered normal body weight.

Typically developed during adolescence, the prevalence rate of anorexia nervosa among females is .4%. Studies show that nearly 50% of clients make a full recovery, 20-30% show residual symptoms, 10-20% remain severely ill, and 5-10% die of related causes. One of the greatest challenges for a therapist is the client's ambivalence about getting well. Diagnostic crossover is common, especially from anorexia nervosa to bulimia nervosa, and is closely monitored in treatment.

What are the medical complications?

Anorexia nervosa has the highest mortality rate of any mental disorder, approximately 5% per decade. In addition, the suicide risk among those with this disorder is fifty times greater than that of the general population. Medical problems include amenorrhea (loss of menstrual cycle), anemia, dry skin, hair loss, feeling cold, slowing of thought processes, osteopenia/osteoporosis, heart rhythm abnormalities, and heart attacks. Starving takes a major toll on health. Therefore, it is critical to get treatment as soon as possible.

What is Eating Disorder Not Otherwise Specified?

This diagnostic category is reserved for eating disorders that do not meet the criteria for a specific eating disorder. The description of binge-eating disorder above is one example. Other examples are meeting all of the criteria for Anorexia Nervosa except that the female individual has normal menses, or the individual's current weight is still in the normal range despite significant weight loss. Repeatedly chewing and spitting out large amounts of food but not swallowing the food is another example. An individual may meet the criteria for Bulimia Nervosa except that binge eating and inappropriate compensatory mechanisms occur less than twice a week or for a duration of less than three months. Finally, an individual of normal body weight may eat small amounts of food and still use inappropriate compensatory behaviors such as vomiting.

What will we do in the first session?

I begin with the assessment by interviewing you in order to get a complete history of the eating disorder. Following this clinical interview, I provide you with questionnaires and tests to complete at home including the Eating Problems Questionnaire, the Eating Disorders Inventory, Personal Problems Checklist, Health Problems Checklist, Incomplete Sentences Blank, Minnesota Multiphasic Personality Inventory (MMPI), and an assessment of character strengths. These assessment tools are available only to licensed clinical psychologists, and are provided at no additional cost. I also provide a handout that describes the hazards of anorexia nervosa and bulimia nervosa.

What do we learn from the assessment?

The results of testing, including graphs, are reviewed in subsequent meetings, and form the basis for treatment goals and planning. For example, The Eating Disorder Inventory (EDI) graph identifies problems in the following areas: preoccupation with restrictive dieting, uncontrollable overeating, and concern about overall shape, global measures of eating and weight concerns, low self esteem, emotional emptiness, interpersonal insecurity, lack of trust in relationships, tendency towards mood instability, perfectionism, self sacrifice, and maturity fears. The graph from the MMPI test identifies elevations in areas including depression, anxiety, need for attention, somatic concerns, reality testing, interpersonal trust, energy level, and relative tendency toward introversion or extraversion. Character strengths assessments help me to identify and build on your strengths. The positive psychology approach is applied to challenges inherent in dealing with and changing eating disorder behaviors.

How do I complete the Signature Strengths assessment online?

You can learn about your particular strengths by following the directions below, and going online to take the Signature Strengths Inventory.

  • Go to Questionnaires
  • Go to VIA Signature Strengths Questionnaire
  • You must register by logging in and identifying a password

What is the prevalence of weight problems among adults?

We live in a culture that values being thin. A resent (2012) survey by The Washington Post and the Henry J. Kaiser Family Foundation, a nonprofit organization that researches health care, randomly surveyed by telephone 1936 adults. Among women in the sample, 44% of white women and 44% of black women reported that they are overweight; 6% of white women and 6% of black women reported that they are underweight. Among men, 39% of white men and 25% of black men reported that they are overweight; 4% of white men and 6% of black men reported that they are underweight. Notably, only 43% of white women and 67% of black women reported having high self-esteem.

How does this study relate to cultural values about being thin?

One of the implications drawn from the poll is that white women like their bodies less than black women do. We live in a culture that values being thin. Social pressure to conform to this norm contributes to body image and self esteem concerns, obsessive thoughts, compulsive behavior, and perfectionism. The core problem for many of my clients with eating disorders involves excessive concern with body shape and weight, which leads to dysfunctional dieting and other unhealthy weight control behaviors, and predisposes some clients to binge eating.

What are common treatment goals, and what techniques do you use?

Treatment for all types of eating disorders consists of cognitive, behavioral, and insight oriented procedures designed to:

  • Engage you in treatment
  • Enhance your motivation for change
  • Replace dysfunctional dieting with a regular and flexible pattern of eating
  • Decrease undue concern with body shape and weight
  • Prevent relapse
  • Incorporate regular exercise and healthy eating patterns in your lifestyle
  • Build your self esteem and sense of competence
  • Develop trust in your body and ability to maintain a normal weight
  • Enhance your comfort with a body mass index (BMI) in the normal range
  • Reduce isolation associated with behaviors that reinforce the eating disorder
  • Appreciate the supportive role others may play in recovery
  • Address cognitions that may contribute to problems with self esteem, perfectionism, insecurity, isolation, and distrust; and that may interfere with the process of independence and self-determination.

This interactive and exploratory approach to the treatment of eating disorders prompts you to identify and modify behaviors, and regulate your emotions during stressful periods when problematic eating behaviors are more likely to arise. Functioning and self-regulation at home, school and/or your workplace; problem solving; vigilance in areas of nutrition, diet, body image, exercise, and sleep; stress management; and social relationships at school, work, home, and in the community are commonly discussed. Social relationships are explored within the framework of understanding how particular self-views, views of others, cognitive beliefs, perceptions of threat and vulnerabilities, strategies, and affect have an impact on the way in which people interact with one another.

Coping, decision-making, and interpersonal skills are reinforced in order to find constructive ways to deal with conflict, identify harassment at school or work and resolve conflicts. Discussions may address when it is and is not feasible to exert control in a particular situation. There is an emphasis in therapy on reduction of high risk eating behaviors and looking to others for support. If I am working with an adolescent, I may work with the adolescent and parent in some sessions in order to set and enforce limits; address the needs of siblings or family members; build family respect and support; and open up channels of communication.

Contacts with family members and other members of the health care team are critical in the treatment of bulimia nervosa, anorexia nervosa, and binge-eating disorder. I routinely refer to pediatricians or internists for medical evaluations, psychiatrists for medication evaluations when indicated, and registered dietitians for nutritional counseling.

Why should I seek your services for myself or a family member?

Nearly eight hundred therapists identified specialists to whom they would send a family member in the most recent Washingtonian magazine ranking of therapists Best of Issue (July, 2009). My peers recognized me as the one clinical psychologist practicing in northern Virginia whose services they would seek for a relative with an eating disorder. I am honored to be the only psychologist practicing in northern Virginia to be included in this category.