Clinical Handbook of Mindfulness (74 page)

2000;
see
Quadflieg and Fichter, 2003
for a review).

Treatment of BN typically involves psychopharmacological agents

(e.g., fluoxetine) and/or some form of psychotherapy (e.g., CBT) or self-help-

based approach. An extensive qualitative review of RCTs published between

1980 and 2005
(Shapiro et al., 2007)
cited robust evidence for both medical and behavioral interventions for significantly reducing core BN symptoms

and promoting relapse prevention, but also highlighted the major challenge

of retaining participants in all therapeutic technologies
(Shapiro et al., 2007).

Binge Eating Disorder

Individuals meeting diagnostic criteria for BED endorse recurrent episodes

of uncontrollable eating binges in the absence of inappropriate compen-

satory behaviors
(APA, 2000).
Secondary features involve eating more rapidly than usual during the binge episode, eating when not feeling physically hungry, eating to the point of being uncomfortably full, feeling guilty, depressed

and/or embarrassed due to excessive food intake and experiencing signifi-

cant distress in reaction to the eating binge
(APA 2000).
These symptoms must occur on at least two days per week over a 6 month period of time

with no more than two weeks of abstinence
(APA, 2000).
Although not a

requirement for diagnosis, a majority of individuals with BED tend to be

overweight or obese
(Hudson, Hiripi, Pope, & Kessler, 2007;
Reichborn-Kjennerud, Bulik, Sullivan, Tambs, & Harris,
2004).
BED remains a research diagnosis and officially is classified as a form of Eating Disorder Not Otherwise Specified (ED-NOS;
APA, 2000).

BED is the most prevalent of the three primary ED affecting between 0.7

and 4% of individuals. U.S. community-based studies cite somewhat higher

rates (2–5%;
Bruce & Agras, 1992)
and BED rates as high as 30% have been reported among obese persons seeking weight loss treatment
(Spitzer et al.

1992;
1993).
Though BED appears to be on the rise across diverse groups, some data suggests that racial disparities in rates of BED are lower than have

been published in previous reports
(Striegel-Moore et al., 2003).
Risk for
262

Ruth Q. Wolever and Jennifer L. Best

obesity and related medical consequences are central physical health out-

comes relevant to chronic BED pathology
(Fairburn et al., 2000).
Like BN, and in contrast to the earlier average age of onset of AN, BED more typically emerges in late adolescence or young adulthood (Office on Women’s

Health,
2000).
The natural course of BED has received less attention in comparison to other ED. Based on the limited literature available, it would seem

that rates of relapse are low at longer-term follow-up
(Fairburn et al., 2000;

Fichter, Quadflieg, & Gnutzmann, 1998)
though more equivocal outcomes were observed in the short-term
(Cachelin et al., 1999).

While the treatment of BED runs the similar gamut of pharmacological,

CBT and self-help based interventions, this smaller evidence base of RCTs

has yielded inconclusive findings (see Brownley, Berkman, Sedway, Lohr, &

Bulik,
2007
for an extensive review). One of the ongoing debates in managing BED in overweight and obese samples is whether to prioritize regulating

eating before targeting weight loss efforts (see Brownley, Berkman, Sedway,

Lohr, & Bulik,
2007
for a discussion). Regarding this challenge, CBT has been effective in producing significant and enduring positive shifts in binge eating pathology but has not been consistently effective in promoting apprecia-

ble weight loss (see
Brownley, Berkman, Sedway, Lohr, & Bulik, 2007
for an overview).

Eating Disorders as Attempts to Self-Regulate: Problem

Formulation and Theoretical Rationale for the Use

of Mindfulness

Over the last several decades, a compelling body of research has suggested

that the core deficits in ED stem from ineffective attempts to self-regulate

(e.g.,
Davis & Jamieson, 2005;
Overton, Selway, Stongman, & Houston, 2005;

Whiteside et al., 2007).
Severe caloric restriction, binge eating and inappropriate compensatory behaviors are conceptualized as attempts to regulate

aversive aspects of experience and may be considered products of stress reac-

tivity. Viewing ED from a functional self-regulatory perspective, four concep-

tual models serve as cornerstones: emotion regulation theory (e.g.,
Gross,

1998; Heatherton & Baumeister, 1991;
Wilson, 1984),
cognitive-behavioral restraint theory
(Herman and Polivy, 1980;
Polivy & Herman, 1985);
cognitive avoidance
(Heatherton & Baumeister, 1991)
and mental control theory

(Wegner, 1994).
These theories posit that ED symptoms attempt to regulate: (1) emotion through behavior; (2) behavior through cognition; and (3) cognition through behavior (mental control). Physiological processes confound

each step of this attempt.

Attempts to Regulate Emotion through Behavior

Individuals with ED have marked deficits in adaptive emotional self-

regulation; that is, they have difficulty accurately identifying emotions, man-

aging them, and using them adaptively
(Bydlowski et al., 2005;
Carano

et al.,
2006;
Gilboa-Schechtman, Avnon, Zubery, & Jeczmien, 2006;
Wheeler, Greiner, & Boulton, et al,
2005).
Higher levels of alexithymia (difficulty identifying and describing emotional experience) are both self-reported

Chapter 14 Mindfulness-Based Approaches to Eating Disorders

263

(Bydlowski et al., 2005;
Wheeler, Greiner, & Boulton, et al, 2005)
and observed
(Berthoz, Perdereau, Godart, Coros, & Haviland, 2007)
in individuals with ED compared to normative samples. Furthermore, higher levels

of alexithymia are related to more disturbed body attitudes, poorer self-

esteem, higher depression ratings and more severe binge eating pathology

among BED patients
(Carano et al., 2006).
Importantly, tendencies toward alexithymia commonly occur in those with an externally oriented, concrete

thinking style
(Sifneos, 1996).

Accurate identification of emotion requires an internal orientation, refined

attention to the physiological component of emotional experience and dis-

cernment between true emotions versus other physical states (e.g., hunger,

fatigue). Poor interoceptive awareness is a hallmark of ED (Fassino, Piero,

Gramaglia, & Abbate-Daga,
2004;
Spoor, Bekker, Van Heck, Croon, & Van Strien,
2005)
and physiological signals of emotion are often confounded with appetite regulation cues. Those who practice strict dieting do not respond

to hunger signals; eventually, hunger becomes paired and confounded with

negative emotion.

Those more prone to binge eating not only have trouble reading hunger

signals, but also have difficulty discriminating the somatic signaling of gastric

satiety as well as taste-specific satiety
(Allen & Craighead, 1999;
Hetherington

& Rolls,
1988).
In all types of ED, this considerable dysregulation in the experience of hunger and fullness is not only related to emotional dysregulation,

but also to dysregulation in the physiology of hunger and fullness. Individuals

with AN may not perceive hunger due to dysregulated processing of insulin

signals
(Nakai & Koh, 2001).
In addition, disturbed activation patterns have been observed in the neurophysiological correlates of somatosensory and

attentional processing of food stimuli on fMRI (Santel, Baving, Krauel, Munte,

& Rotte,
2006).
Furthermore, subjective hunger ratings are negatively correlated with preoccupation with eating, weight and shape (Spoor, Bekker, Van

Heck, Croon, & Van Strien,
2005).

Skills in emotion identification not only rely on a highly attuned sense of

interoceptive awareness, but are also facilitated by acceptance of emotional

experience. Conversely, when emotions are labeled as pathological, individ-

uals tend to binge eat, use substances or dissociate in an attempt to reduce

awareness of emotion (e.g.,
Leahy, 2002).
Moreover, individuals with ED may avoid emotion in part because they hold inaccurate beliefs about the nature

and consequences of emotions
(Linehan,
1993a;
Corstorphine, 2006).

Individuals with ED have difficulty managing and utilizing emotion adap-

tively. They tend to use eating as a way to avoid or escape negative emotional

states and to create more positive states. For example, stress, pain and neg-

ative affect are common antecedents to binge eating
(Agras & Telch, 1998;

Davis & Jamieson, 2005;
Gluck, Geliebter, Hung, & Yahav, 2004;
Lynch, Everingham, Dubitzky, Hartman, & Kasser,
2000;
Stein et al., 2007).
When faced with negative emotion, those with ED have a limited range of emotion regulation strategies available (e.g., binge eaters in a college sample
Whiteside et al.,

2007);
binge eating and compensatory behaviors are used to escape aversive experience by escaping self-awareness altogether (Heatherton & Baumeister,
1991).
Attention is narrowed, focused externally, and inhibitions against bingeing or purging are reduced. This is consistent with the finding that

264

Ruth Q. Wolever and Jennifer L. Best

alexithymia commonly occurs in those with an externally oriented, concrete

thinking style
(Sifneos, 1996).

Difficulty regulating emotion is further complicated by the fact that indi-

viduals with ED may be prone to greater stress reactivity in light of identified

biological vulnerabilities (e.g., elevated cortisol, cardio-vagal abnormalities:

Faris et al., 2006; Gluck et al., 2004;
Kollai, Bonyhay, Jokkel, & Szonyi, 1994;

Petretta et al., 1997).
In addition, they have greater difficulty accepting and managing distress
(Corstorphine, Mountford, Tomlinson, Waller, & Meyer,

2007).
In fact, emotional eating has emerged as a more general avoidant coping style in a broad range of clinical and non-eating disordered samples (Lin-

deman & Stark,
2001;
Spoor, Bekker, Van Strien, & van Heck, 2007).
Individuals with ED may also use eating and compensatory behaviors to produce a

more positive emotional state
(Overton et al., 2005).
Purging, for example, is often enacted to relieve the overwhelming emotional distress experienced

following an eating binge
(Corstorphine, Waller, Ohanian, & Baker, 2006).

Rationale for Mindfulness Approaches Based on Emotion Regulation

Mindfulness offers a strong opportunity to improve emotion regulation. It

trains individuals to focus inwardly in a highly externally oriented culture,

cultivates an acceptance of emotion as a part of human experience, and

allows individuals to practice identifying and experiencing emotion without

reacting to it. At the same time, mindfulness techniques applied specifically

to eating allow individuals to tease apart physiological cues of emotion with

those of hunger or satiety.

Interplay of Behavior and Cognition in Self-Regulation

Attempts to Regulate Behavior through Cognitive Rigidity

My body started to shut down. I got really, really ill. When you’re starving

yourself, you can’t concentrate.

I was like a walking zombie, like the walking dead.

I was just consumed with what I would eat, what I wouldn’t eat
.

∼Tracey Gold, Actor

ED populations are characterized by rigid and distorted cognition in rela-

tion to eating patterns, perfectionism, and appearance-related thinking. They

attempt to regulate behavior through a rigid cognitive-behavioral orienta-

tion of restraint
(Herman & Polivy, 1980;
Polivy & Herman, 1985).
Such restraint with respect to eating is obvious in anorexia, but is also prominent in those with bulimia and binge eating disorder. Individuals who diet

in order to lose weight internalize a set of stringent dietary rules that result

in highly restricted caloric intake that deprives the body of essential nutrients

and energy. In response to this chronic state of “starvation,” some individu-

als experience the urge to binge as too overwhelming to avoid (Polivy &

Herman,
1985).
Inflexible dietary rules are overridden by this physiological urge and the abstinence-violation effect often results in a full blown eating

binge
(Agras & Telch., 1998).
Consequently, dieting and related thought patterns are inherent in the emergence and maintenance of eating pathology.

Behavioral restraint in the form of dieting has also been longitudinally

predicted by appearance-related beliefs in structural equation modeling

Chapter 14 Mindfulness-Based Approaches to Eating Disorders

265

(Spangler, 2002).
Similarly, appearance-related beliefs predicted body dissatisfaction and other vulnerabilities to eating pathology across time points in

an ethnically diverse group of adolescent females. Furthermore, statistical

modeling failed to support a bi-directional relationship over time
(Spangler,