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Binge Eating

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Introduction

In our society, we have several different types of eating dysfunctions, all of which are unique and tragic. Despite their individuality, they all have several overlapping symptoms that are important to their classification and severity. For Bulimia Nervosa (BN) and Binge Eating Disorder (BED), one of the core features is binge eating, which can be defined objectively by number of calories eaten in a given time or subjectively by the feelings of the binger. Binge eating has many different aspects that are of interest to scientists and clinicians. One of those interests has to do with the reduction of this symptom among populations being treated for their respective disorder. Because both disorders are relatively new to the scientific and clinical world, there is much debate over how to treat, define, and possibly distinguish the occurrence of the two disorders. For the purpose of this paper, I intended to examine the evidence for the best outcomes, both immediate and long term, for reduction of binge eating in these disorders.

Clinicians treat BN and BED in several different ways, some of which are more effective than others, especially at reducing the core symptom of binge eating. Although many treatments exist, those most researched in terms of treatment outcome are interpersonal therapy (IPT), cognitive behavioral therapy (CBT), behavior therapy (BT), and pharmacological therapy. These treatments are not designed to simply treat binge eating; instead, they are used to treat the whole disorder (ex: anorexia or bulimia). Although these treatments look at the bigger picture, by understanding the workings of the therapy and differences in treatment outcomes among core features, science can expand upon its understanding of the causes of BN and BED. Thus, it is important to know which therapies affect which symptoms effectively.

Therapies used.

Interpersonal therapy (IPT) is imitative of therapy designed for depressed individuals, which originated from the New Haven-Boston Collaborative Depression Project (Fairburn et al 1993). It borrows from the psychodynamic school of psychology, but concentrates on interpersonal functioning and involves three steps: 1) the first is an intensive analysis of the interpersonal context which the disorder develops and is maintained 2) the second involves addressing the interpersonal problems and contracting with the patients to work on these problems 3) the third deconstructs feelings about ending therapy, reviews progress and outlines future work (Fairburn et al. 1993).

Cognitive behavioral therapy (CBT) is currently the most commonly used type of psychotherapy (Peterson & Mitchell 1999). It is based on the cognitive view of bulimia nervosa, which weighs attitudes towards shape and weight as most significant for maintenance of the disorder. Therapy actually includes a combination of behavioral and cognitive commands aimed at changing patterns of behavior, attitudes of shape and weight, and cognitive distortions such as low self esteem (Fairburn et al. 1993).

Behavioral therapy (BT) is similar to CBT but concentrates on behavioral procedures used to regulate eating habits. The major features are regaining control over eating, establishing a regular pattern of eating, and ending of dieting (Fairburn et al. 1993). The last is a controversial issue with BED because of the high incidence of obesity in this disorder (Wilfey et al. 1997).

Pharmacotherapy is the use of drugs, mainly selective seratonin reuptake inhibitors (SSRI) or MAO inhibitors. The list of these antidepressant drugs includes imipramine, desipramine, phenelzine, bupropion and fluoxetine (Agras et al 1992). The use of strictly pharmacological treatment is pushed by one study to be the most cost-effective treatment for eating disorders (Agras 1997). Readers of this study must realize biases are present in science and this comment may reflect the views of the author, W. Stewart Agras, who is a MD and not a clinical psychologist.

Review.

Several review papers have looked at the question of which type of therapy is most effective in treating bulimia nervosa and binge eating disorder (Peterson & Mitchell 1999; Wilfey et al 1997), but little detail is discussed about the reduction of binge eating specifically. CBT is the psychotherapy most successful in immediate reduction of symptoms, including binge eating, and long-term abstinence from the characteristics of each disorder (Wilfey et al. 1997). Wilfey et al. (1997) claims that long-term effects of IPT are comparable to CBT in cases of BN, but not enough is known about treatment for BED to make any firm conclusions. What is interesting about this conclusion is that IPT does not deal directly with behaviors associated with eating disorders, yet it is successful in reducing the core symptoms of BN.

The debate between psychotherapy and pharmacotherapy is at least two-dimensional. The first dimension is less scientific and more important to clinicians who face more pressure to efficiently and effectively serve their patients. Although, Agras (1997) claims that 24 weeks of medical treatment was 1,982$ and 3,230$ for CBT, the reality of the problem of cost comes from health insurance coverage plans and the influence of drug companies on this system. It is an issue too broad for this paper, but one worth mentioning because it is vital to the reality in treatment of eating disorders. The second dimension is that of true effectiveness. Peterson & Mitchell (1999) conclude that CBT is the most effective psychological therapy and more effective than medication alone. However, they concede that a combination of medicine and CBT is moderately more effective than CBT alone for reducing symptoms of BN.

With this background discussed, the rest of the paper looks at the experimental evidence that measures the effectiveness of treatments on a number of core symptoms. Only the results on reduction of binge eating will be discussed in hopes of determining if the core symptom of binge eating should be thought of as identical in both BN and BED as well as determining which therapy is most effective at reducing binge eating.

Fairburn et al (1993) studied the effectiveness of three psychotherapies on the frequency of binge eating and purging in seventy-five consecutively referred cases of BN. The only exclusion criterion was concurrent anorexia nervosa, which may have allowed incidences of depression or personality disorders to complicate the data since they do occur with BN (Wilfey et al. 1997). An additional problem that occurs in many of the clinical trials (Wilfey et al. 1997) is attrition rate. In this particular study, the BT group lost 48% of its sample by the final assessment and a

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