Total Wellness Inc. Cognitive Behavior Therapy of Eating Disorders   Welcome to the CBT group. This is a 12 week group for individuals with abnormal eating behaviors. The group meets Saturdays at 11am starting July 12, 2008. We also offer a men's group at 12.00 noon on Saturdays addressing eating issues in men. Please call us at 4106050180 to join or email vvaidya@obesitypsychiatry.com. Introduction Eating behavior patterns that result in disease or difficulties in an individual’s life are defined as “abnormal eating behaviors”. These could be eating related to emotions such as stress or boredom, eating when already full, eating when not hungry. It is mostly about impulse control and triggers related to eating. Many patients report that they never feel satisfied; they are looking for something else besides curbing their hunger, in food. Binge eating was first described by Stunkard in 1959 as a behavior seen in certain obese individuals that consisted of, uncontrolled consumption of objectively large amounts of food. Although it is not limited to obese individuals, BED is most common in this group. Those who seek help, usually do so for being overweight rather than for the binge eating. Prevalence of BED has been estimated to be about 2-5 % in a community survey, 30-40 %in treatment seeking obese patients and probably higher in “super obese” patients. Individuals in Overeaters Anonymous had a prevalence of 70% for BED. BED is more equal in gender ratio than bulimia nervosa and has a similar prevalence among racial groups.   BED is characterized by: Recurrent episodes of eating uncontrollably indicated by 1.      eating more rapidly than usual 2.      eating until feeling uncomfortably full 3.      eating large amounts of food when not hungry 4.      eating alone 5.      No planned mealtimes 6.      eating in response to emotions 7.      guilt about over eating ·        Binge eating occurring at least twice a week for a 6 month period.   This is differentiated from Bulimia Nervosa (BN) by the lack of compensatory mechanisms such as purging/ laxative abuse. Bulimics have a greater size of a “binge meal” as compared to patients with BED. Although patients with BN consume fewer calories than patients with BED, they tend to have a more disturbed pattern of eating. BED is associated with increased psychopathology including depression and personality disorders. There are thought to be subtypes of BED; those driven by psychological factors versus those driven by physiological factors the differentiation being important tool to help focus treatment strategies. Psychologically driven binge eating refers to patients eating in response to stress or depression. Physiologically driven binge eating can result from semi starvation and restricted eating which can lead to preoccupation with food. If eating is initiated in a state of intense hunger reactive overeating can occur, or if restrained eating is disrupted via disinhibition. Another syndrome has been identified as causing disturbed eating patterns, night eating syndrome. Night eating syndrome is defined as skipping breakfast more that four days a week, consuming more than 50% of calories after 7pm and difficulty falling asleep or staying asleep more than 4 days a week. The prevalence of NES in pre bariatric patients is reported to be as high as 26% and about 27% 32 months post op.

Cause of BED As with most eating disorders, the cause of BED is multifactorial including genetic, social and psychological influences. Overeating represents lack of interoceptive awareness and inability to discern internal cues. Studies have shown no evidence that binge eating results from dietary restraint in obese patients. About half the patients with BED report that they first started to binge in the absence of dieting. Disinhibition as opposed to dieting seems to precipitate binge eating in many obese subjects. Negative emotional states such as frustration, anger depression and anxiety, social situations, and type of meal have been known to trigger an episode of binging. There are few studies on the physiological differences between obese patients with and without binge eating, with any evidence to suggest that obese patients with BED had more medical consequences of obesity than those without BED. There are significantly higher levels of psychiatric symptoms in patients with BED as compared to those without BED. Furthermore depressive symptomatology may increase the patient’s vulnerability to binge eating as well as to relapse after treatment. BED is thought to be associated with exposure to risk factors for psychiatric disorders like parental depression, childhood sexual or physical abuse, negative self evaluation, and pregnancy before onset. They were also associated with exposure to risk factors for obesity, childhood obesity, and critical comments by family about shape, weight or eating. Other antecedents of binge eating are low alertness, feelings of low control over eating and craving sweets. Grazing is a condition that may arise from “boredom, mindlessness” or be compulsive or emotional in nature. It is defined as eating small amounts of food continuously. BED in the pre bariatric patient can manifest as “grazing” about 2 years post bariatric surgery. The patient learns to “eat around the surgery” resulting is weight regain in these patients. It has been reported that some patients, feel a loss of control over eating as early as six months post bariatric surgery. Body image dissatisfaction is more pronounced in obese patients with BED than in obese non- binge eaters. Treatment Successful treatment of binge eating may not affect much weight loss; however it does tend to stabilize weight in comparison to the upward weight trend in patients who continue to binge. Some hold the view that treatment should be directed at disordered eating and associated psychopathology first and only after control of binge eating should additional weight loss measures be considered. However several studies have shown that weight loss treatments including bariatric surgery do not exacerbate binge eating. In fact patients with the most severe binge eating behavior showed the most improvement especially in the short term. Patients with BED prior to surgery tend to relapse into some of their previous behaviors, albeit to a lesser extent. They are unable to consume as much as the used to at one time, however they become grazers and thus tend to gain some weight back about 2 years after surgery. Given that obesity is frequently present in patients with BED and raises the patient’s medical morbidity, it is important to consider interventions that also produce weight loss. Treatment should be directed at eating behavior, associated psychopathology, weight and psychiatric symptoms. Treatments should be appropriately modified to better fit a post bariatric surgery patient. Traditionally eating disorder patients are encouraged to have “three fixed meals”. Bariatric surgery patients have to eat small frequent meals. Their dietary restrictions and changes need to be reflected in a modified program to fit their needs. Bariatric surgery patients also tend to be, more preoccupied with food post operatively; this seems to be more of an attempt to comply with treatment and usually reduces as their habits get more routine.

Cognitive Behavior Therapy: Cognitive behavior therapy is based on changing the individual’s erroneous ways of thinking about themselves, the world and how others perceive them. It is thought that individual’s disordered “schema” of thoughts perpetuates self defeating behaviors and causes depression, anxiety and eating disorders. It has been well studied and shown to be highly effective for treatment and prophylaxis of depressive and anxiety disorders. It was modified for treatment of Bulimia Nervosa and more recently for Binge Eating disorder. This includes a focus on normalizing food intake as well as challenging dysfunctional thinking, identifying feelings, and developing non-food coping skills. It increases a sense of control and therefore helps the patient adhere to behavior change strategy, as well as improving mood and reducing associated psychopathology. The process can be divided into several phases Phase I: Involves developing a therapeutic relationship with the therapist and other group members Getting to know the nature of binge/emotional eating and factors thought to maintain the problem. Keeping a diary for self- monitoring of food intake, helps to identify the disordered eating, while working towards a normalization and structured or regular pattern of eating For post bariatric surgery patients, the focus is on the dietary adjustments, loss of their “friend” food, their changed relationship to food, changes in their bodies and their relationships with others. Phase II Identify and challenge maladaptive thoughts regarding eating and weight/ shape. Identifies thoughts that are triggers for binge/emotional eating. Use cognitive restructuring techniques to normalize eating patterns. For the post bariatric surgery patient special attention is paid to body image and relationships. The rapid loss of weight post operatively can result in disruption of the “homeostasis” of the relationship with their partner and result in relationship difficulties Phase III Focuses on maintenance of change and relapse prevention Identifying high risk situations and developing a relapse plan. The group usually works well with 6-8 patients meeting weekly and can last for 12 weeks with the ability for patient to return if needed as well as additional individual therapy as needed. Interpersonal Therapy This was initially developed to treat depression, later modified for the treatment of bulimia nervosa and most recently for the treatment of BED. IPT does not focus on eating behavior, but on relational factors associated with the onset and maintenance of binge eating. It is based on the relationship between negative mood low self esteem traumatic life events, interpersonal functioning and the patient’s eating behavior. The rationale being that eating represents maladaptive coping with underlying difficulties.   Conclusion Cognitive behavior therapy has clear positive effects on behavioral and psychological features. Studies suggest that patients who are in remission from binge eating achieve greater weight loss than those who are not in remission. It has been suggested that adding exercise to CBT as well as extending the duration of treatment improves outcomes and reduces binge eating. The key to maintaining weight loss is the ability to continue a diet and exercise program “forever”. It is therefore best to adopt a lifestyle change rather than diet for periods of time. Adding good eating habits and exercise and reducing abnormal eating helps improve physical and mental health. The goal of CBT groups is to use cognitive exercises to change deeply ingrained patterns of erroneous thoughts and behavior and thus setting the person free.