Senior Project Final

Literature Review on Mindfulness Cognitive Behavioral Therapy Treatment for
Binge-Eating Disorder
Kyra Benson
December 2014
Concordia College-Moorhead, Mn

Mindfulness Treatment for Binge-Eating Disorder
2
Introduction
There are a variety of eating disorders that range from an individual
restricting his or her diet in order to lose weight (Anorexia Nervosa) to an
individual eating a large amount of food in one sitting (Bulimia Nervosa or Binge-
Eating disorder). Each disorder has different symptoms and different concerns to
be addressed in diagnosis and treatment. This literature review will first discuss
how Binge-Eating disorder is different from other eating disorders, then it will
examine why Cognitive Behavioral Therapy is an effective form of treatment for
eating disorders. Then the Mindfulness treatment that exists within Cognitive
Behavioral Therapy, is examined in how it is used to treat not only the symptoms
of Binge-Eating Disorder but also examining the thinking patterns that underlie
the disorder. This Mindfulness treatment is also compared to the Dialectical
Therapy Treatment, which will be used as a form of comparison
Background
General Eating Disorders
According to the Diagnostic and Statistical Manual of Mental Disorders
(DSM)(2013) eating behavior patterns are characterized as an eating disorder if
the eating behavior alters the amount of food consumed or the manner in which
food would be consumed. This behavior must also significantly impair health and
functioning of the individual. There are many different types of eating disorders
but the most common ones are Anorexia Nervosa, Bulimia Nervosa, and Binge-
eating disorder. In previous versions of the DSM there were three categories:

3
Anorexia Nervosa, Bulimia Nervosa, Eating Disorder Not Otherwise Specified
(NOS). But in the DSM-V, Binge-eating disorder was added as a separate
category. This allows for research to be done not only in the diagnosis for Binge-
eating but also in the treatments that are available.
In order to be categorized as suffering from Anorexia Nervosa an
individual must be restricting the amount of food being consumed which leads to
extreme weight loss. The other key symptom of Anorexia is the distortion in the
perception of his or her own body (i.e., the individual is unable to see the degree
of weight loss) (DSM-V, 2013). According to the Anorexia Nervosa entry in the
Gale encyclopedia of Mental Health, Anorexia Nervosa is most common for
women in their late teens and is characterized by the fear of gaining weight,
which can lead to extreme weight loss and malnourishment.
Another type of eating disorder, known as Bulimia Nervosa is
characterized by the following set of criteria. Individual suffering from Bulimia
Nervosa, experiences reoccurring episodes which consists of eating an unusually
large amount of food in a short amount of time accompanied by lack of feeling in
control of behavior during this time. This reoccurring inappropriate behaviors to
compensate for weight gain (self-induced vomiting, use of laxatives etc.), and the
behavior occurs at least once a week for duration of three months. This disorder,
like Anorexia Nervosa, affects mainly women in their late teens. Bulimia Nervosa
is characterized by compulsive overeating followed by purging (Fundukian 2008).
Information on Binge-eating Disorder

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According to Tanofsky-Kraff et. al (2013), Binge-Eating Disorder is
defined as a serious eating disorder (often referred to as overeating) that is
characterized by frequent consumption of a large amount of food over a limited
period of time. This differs from Anorexia Nervosa in the fact that the individual is
not restricting the amount of food they intake. It is also different from Bulimia
Nervosa. Although both disorders include the overconsumption of food in a small
amount of time, Binge-Eating Disorder does not include purging or other attempts
to compensate for the increase in caloric intake. However some individuals
suffering from Binge-eating disorder do attempt to diet in between binge-eating
episodes. Unlike Anorexia Nervosa and Bulimia Nervosa, Binge-Eating Disorder
affects both women and men (although it is more common among women). This
disorder typically begins in late adolescence but also occurs into middle
adulthood. Binge-eating disorder is different from other abnormal eating patterns
such as continuous snacking, since these individual suffering from Binge-Eating
Disorder overeat in the absence of hunger.
The following consists of the general characteristics of Binge-Eating
Disorder. The defining characteristic of Binge-Eating Disorder is the loss of
feeling in control of their eating habits (Tanofsky-Kraff et. al, 2013). According to
the Diagnostic and Statistical Manual of Mental Disorders (2013) there are set of
specific characteristics that all must be met in order for the pattern of eating
behavior to be classified as Binge-Eating Disorder. One of these characteristics
is the reoccurrence of binge-eating episodes. An episode consists of eating what
would be considered a larger amount than most people would eat in a short

5
amount of time, combined with a lack of control over their eating habits during
that time. Also within these episodes three of the following five characteristics be
must associated with the episode: eating more quickly than normal, eating until
feeling uncomfortably full, eating large amounts of food when not feeling hungry,
eating alone because of embarrassment, feeling disgusted, depressed or guilty
afterwards. There also must be a feeling of distress over their binge-eating
behavior. Finally the binge-eating behavior must occur at minimum once a week
for three months. Binge-Eating behavior is not being associated with
inappropriate compensatory behaviors, such as with bulimia and does not occur
in the course of Anorexia Nervosa or Bulimia Nervosa (DSM-V, 2013).
In addition to all these criteria, there are also criteria for the severity of the
Binge-Eating Disorder. The following are the classifications for severity: mild
consists of 1-3 binge-eating episodes per week, moderate consists of 4-7 binge-
eating episodes per week, severe consists of 8-13 binge-eating episodes per
week, and 14 or more binge-eating episodes per week results in being classified
as extreme (DSM-V, 2013).
According to Tanofsky-Kraff et. al (2013) the issue of the symptoms of
Binge-Eating Disorder are often hard to classify since the maladaptive behavior
typically takes place when the individual is alone. However here are some of the
symptoms of Binge-Eating Disorder: feeling out of control when eating, not being
able to stop eating once they have started, continuing to eat after feeling full,
eating large amounts (sometimes as much as 10,000 calories), eating very
quickly and alone or in secret, hoarding food, dieting without weight-loss,

6
obsession with body weight, depression or anxiety, and substance abuse. As can
be seen from the list, those people close to the individual with binge-eating
disorder easily overlook many of these. This is one of the challenges that exist to
diagnosing and treating this disorder (Tanofsky-Kraff et. al , 2013).
In addition to having difficulties identifying those suffering from this
disorder, there are also problems when it comes to identifying the etiology.
Tanofsky-Kraff et. al (2013) discussed the following causes associated with
Binge-Eating Disorder. There seems to be a genetic disposition towards Binge-
Eating Disorder. In addition to hereditary factors, other risk factors include:
frequent dieting or frequent weight fluctuation, poor impulse control, difficulty
expressing emotions, and low self-esteem. Whatever the contributing factors
may be Binge-eating disorder seems to be a coping mechanism, because it
temporarily alleviates uncomfortable feelings. The behavior itself often leads to
more negative feelings, which perpetuates the cycle (Tanofsky-Kraff et. al, 2013).
These are the symptoms and concerns to be addressed when treating Binge-
Eating Disorder, next the treatment of Binge-Eating Disorder will be discussed.
Background on Cognitive Behavioral Therapy
According to Ivey and Andrea (2012), Cognitive Behavioral Therapy is
often an effective form of treatment for maladaptive behavior because it involves
the alteration of behaviors as well as cognition. Cognitive Behavioral Therapy is
the hybrid of cognitive therapy and behavior modification therapy. Cognitive
Therapy focuses on the idea that anxiety results from patterns of thinking and to

7
address this anxiety the patterns of thought must be addressed. Behavioral
modification therapy focuses on changing the behavior through direct
observation. In these two disciplines one focuses exclusively on cognition and
the other focuses exclusively on behavior, with no intersection existing between
the two. The reason that Cognitive Behavioral Therapy is so effective is that it
combines the two approaches. When examining eating disorders, not only is the
behavior damaging to the individual but also the thoughts that are causing the
behavior (Ivey and Andrea, 2012).
CREATE TRANSITION
Background on Mindfulness
According to an article on Dialectical Behavior Therapy for Binge-Eating
Disorder (1999), Binge eating is used as a means to avoid the awareness of
painful emotions. Mindfulness meditation is a means to teach awareness of
emotions and bodily sensations. What makes this different from other awareness
treatments is the idea that is awareness of the particular moment and
acknowledging the sensations without passing judgment on them. It is a
paradoxical observation because even though the individual is bringing
awareness to the experience, they are viewing in a non-judgmental way. This is
particularly important because the use of the technique of mindfulness is
designed to reduce emotional response such as shame and guilt, which are so
prevalent in Binge-Eating Disorder. This is due to the fact that once negative
emotions has been triggered, the binge eating behavior is utilized as means to
distract themselves from the uncomfortable emotions (Wiser 1999).

8
Binge-Eating Disorder Treatment Evaluation
Mindfulness Treatment
Average Population Participants
In a study done by Smith (2006), used average population
participants recruited 25 adult men and women at the University of New Mexico
for an 8-week mindfulness program. The course was advertised as Mindfulness
Based Stress Reduction program with no mention of any emphasis on binge-
eating behavior in the advertisement. This study used MBSR as a starting point
for the purpose of the study. This study followed the Mindfulness Based Stress-
Reduction (MBSR) course: 3 hour-long weekly group session where the aim was
to increase mindfulness through techniques such as breathing, meditation, Hatha
yoga and group discussion as well as tasks to practice at home. This program
(different from MBSR) also had a component focusing on eating mindfully,
progressing from snacks to meals. The program was evaluated through a
questionnaire before and after the course. In addition to that multiple measures
were used including Binge eating to rate the severity of those behaviors. The
results demonstrated that for those participants with binge-eating behaviors the
program significantly decreased the behavior (consistent across all severity
levels) (Smith, 2006).
This study is a good introduction to mindfulness as a treatment for Binge-
Eating Disorder. It established that mindfulness when directed to behaviors
towards food decreases the binge eating behaviors. This relationship was

9
established through the use of volunteers who were unaware that this was the
focus of the program. To improve on this study, a program that focuses on
mindfulness and disordered eating behavior should be done with participants that
are knowledgeable on the intent of the study to determine the applicable effect of
this treatment.
In another study done by Masuda (2010) using the general population
focused on Mindfulness as means of mediating the relationship between the
cognition patterns behind disordered eating patterns and psychological distress.
The participants were recruited from undergraduate psychology classes and
asked to complete a survey. The survey in this study utilized three measures to
assess disordered eating. The disordered eating-related cognitions measure
consisted of a 24-item self-report questionnaire that evaluated the distorted
cognitions related to eating disorders. This was measured on a 5-point Likert
scale and addressed issues such as the fear of weight gain, the need to be thin
or attractive in order to be socially accepted, self-esteem based on weight gain,
and controlled eating habits. The measure of mindfulness was assessed using a
15-item questionnaire using a 6-point Likert scale to evaluate the frequency of
mindlessness in daily behaviors. The measure of general psychological ill health
used a 10-item questionnaire using a 4-point Likert scale, where the participants
were asked to rate frequency of stressor. The final measure that was used was
the Emotional Distress in stressful interpersonal and emergency situations, which
was evaluated on a five-point scale. The results of this study demonstrated that

10
the lack of mindfulness was an important predictor for general psychological ill
health and emotional distress (Masuda, 2010).
This study is a good starting point for the research of mindfulness as
therapeutic treatment. They established that there is a relationship between the
lack of mindfulness (mindlessness) and poor psychological health as well as
emotional distress. This is an important connection to make following the
previous study, since this type of treatment not only affects the disorder eating
behaviors themselves but also psychological health in general. A weakness of
this study is that although the researchers determined that there is a relationship
between these variables, they did not evaluate what type of relationship or the
strength of the relationship. Also the researchers evaluated the lack of
mindfulness but did not evaluate mindfulness itself. This is a good preliminary
study to initiate this area of research but does not carry much significance other
than that.
Obese/Overweight Participants
A study done by Kristeller (1999) 21 women responded to an
advertisement for women struggling with their weight and Binge-Eating. These
women met the criteria for diagnosis of Binge-Eating Disorder but were not
currently in weight loss program or psychotherapy that would interfere with
results of this study. These women were diagnosed by professionals that were
part of the research team prior to the start of the study. Seven sessions were
conducted over a 6-week period, where the primary focus was utilizing
mindfulness meditation in the following ways: general mindfulness meditation,

11
eating meditation, and mini-meditation. General mediation focuses attention,
taking note of thoughts, emotions and being aware of bodily sensations. Eating
meditations applies this specifically to thoughts and emotions related to food,
where as mini-meditations are to take a few moments and become aware of
thoughts and feelings. As a result of this study, both the number of binges per
week as well as the Binge-Eating scores dropped significantly, but no overall
change in weight (Kristeller, 1999).
If evaluating this study as a weight loss treatment, it would be seen as
ineffective since there was no overall change in weight. However it was one of
the first treatments that attempted to adapt Mindfulness-based techniques in a
program that was specifically designed for weight loss. This is a shortcoming of
many treatments for binge-eating disorder. However if this study were evaluated
for the reduction of binge-eating behaviors, it would be seen as effective. Not
only did the binge eating behaviors decrease, there was a significant increase in
feeling of control over eating (which is one of the major symptoms of Binge-
Eating Disorder) as well as awareness of hunger cues. A weakness of this study
is the restrictive sample: small number of only women with ages or history of
binge eating behavior not addressed.
In a study done by Tapper (2009) 62 women who were trying to lose
weight joined a program that utilized mindfulness-based weight loss intervention
as part of the weight loss program. In addition to weekly meetings with a dietitian
and exercising, participants attended three separate one and a half hour
mindfulness workshops, where they were given things to practice between the

12
sessions. This was the experimental group. The control group only had the
dietitian consultations and exercise. The study was evaluated through the use of
the body mass index scale as well as several disordered eating behavior scales,
including the Binge-Eating scale. The results showed that participants who were
in the group attending the mindfulness workshop had greater decreases in body
mass index and binge eating scale scores (Tapper, 2009).
This study used mindfulness as an aspect of the treatment, but it was not
the main focus of the treatment. As mentioned previously, in many of the other
studies looking at weight loss and the use of Mindfulness, the use of Mindfulness
typically does not result in weight loss. However in this study, the reduction of the
body mass index score is most likely a result of the combination of the
mindfulness technique and the change in diet and exercise. But they do not
make clear which effects were results of the diet and exercise changes and
which were due to the mindfulness intervention. Although they did state that the
decrease on the Binge Eating Scale was due to the mindfulness intervention.
However the combination of these treatments makes it difficult to determine
which was the cause of the effects of the treatment.
Participants with eating disorders
A study done by Leahy (2008), looked at the mindfulness technique
in a group therapy context. The participants were 7 individuals who had just
received weight reduction surgery and were having difficulty regulating their
eating behaviors after the surgery. The treatment consisted of the following four

13
stages. The first stage consisted of psychoeducation, enhancing motivation,
begin regular self-monitoring, development of insight into eating triggers. The
next stage focused on giving group member 5-6 small meals per days, controlling
portions as well as external triggers, not drinking or engaging in other behaviors
while eating. The focus of the third stage was to change problematic thought
processes, increase mindfulness practices, and improve coping skills. The last
stage focused on solidifying newly learned behaviors and ways of thinking, as
well as mindfulness techniques and emotion regulation strategies. The results of
this study showed significant improvement in binge eating behaviors (Leahey,
2008).
This was a very thorough and detailed study. The researchers very clearly
laid out what was to be accomplished in each stage and how that was to be
achieved. They said that there was significant improvement shown but not more
than that and not many details were included. Also in their study they did not
address how this study could be applied to other areas. This would be a tricky
study to apply to other areas because of the sample that was used in this study.
A study done by Alberts (2012) focused on using the mindfulness
technique to address and reduce the problematic eating behaviors. In this study
they focused on three disordered types of eating behaviors: restrained, emotional
and external eating. Restrained is restricting the amount of food consumed.
Emotional and external eating is engaging in eating behaviors in response to
external cues instead internal cues such as hunger.

14
Participants were recruited through advertising for individuals with
problematic eating behaviors, who were then asked to answer a variety of
questionnaires before and after treatment including the following: Kentucky
Inventory Mindfulness Skills Extended (used to measure the change mindfulness
skill) Dutch Eating Behaviour Questionnaire, Body Shape Questionnaire (Alberts
2012).
The treatment plan consisted of five main concepts. One was the use of
mindful eating where the awareness is focused on sensations such as taste.
Another concept that was used was the awareness of physical sensations such
as hunger. There was also inclusion awareness of thoughts and feelings related
to hunger. Acceptance and lack of judgment of sensations, thoughts, feelings
and body was also emphasized. The final concept focused on in this study was
the awareness as well as progressive steps to change daily patterns of eating.
The results of the study demonstrated that the participants in the mindfulness
conditions showed significantly greater decreases on measures of food cravings,
concern over body image, as well as emotional and external eating than those
participants who were not in the condition (Alberts, 2012).
This study focused on aspects that were not the reduction of the specific
disordered eating behavior. Instead this study focused on what effect the
mindfulness treatment had on the underlying causes of eating disorders. This is a
much more effective form of treatment when you can address the cause of the
behaviors as opposed to only addressing the behaviors. This study, as opposed
to the previous study, was very clear in the outcomes of their study. One issue

15
with this study is the fact that they don’t address the gender of the participants. It
is support that the majority of individuals suffering from eating disorders or those
types of behavior are women, but that doesn’t mean that men don’t suffer from it
as well.
A study done by Butryn (2013) focused on the relationship that
mindfulness has with eating disorder symptomatology, as well as how changes in
mindfulness effects changes in it. This study looked specifically at women who
are receiving residential treatment. Eighty-eight women participants, who were
currently admitted to two specific residential treatment facilities for eating
disorders participated in this study (the names of the facilities were not included
in the published research study). Measures of mindfulness and symptomatology
of eating disorders were administered before admission and after being
discharged from the facility. The results of this study demonstrated that as
mindfulness improved, so did the symptomatology (Butryn, 2013).
This study was very beneficial in the fact that it measured the effect of
mindfulness while the participants were being treated in a residential facility. This
demonstrates the effectiveness of the mindfulness technique in controlled
treatment environments. Whereas most other research has focused on the
Mindfulness technique in situations where the individuals come and get the
training and then go home. A weakness of this study is that they simply
measured before admission to the facility and after being discharged from the
facility but provided no information on how the mindfulness technique was
implemented.

16
Dialectical Behavior Treatment
The previous studies have all examined the mindfulness treatment in
addressing either Binge-eating disorder or the causes behind the binge eating
behaviors. This next section looks at how the Dialectical Behavior Therapy
treatment compares to the Mindfulness Treatment.
In a study done by Telch (2001) looked at dialectical behavioral
therapy for Binge-Eating Disorder. This study had 44 female participants that met
the full diagnostic criteria for Binge-eating disorder (but also could not be
involved in any psychotherapy or weight loss treatment), and enrolled in program
after seeing advertisement for free treatment through a Stanford University
research study. The participants were assessed both before started treatment
and after completing 20 weeks of treatment. They were assessed through
structured interviews, questionnaires, and measurements of height and weight.
The treatment consisted of 2-hour long weekly session for 20 weeks in which the
therapist focused on mindfulness skills, emotion regulation skills, and distress
tolerance skills. By the end of the treatment 89% of women had stopped binge-
eating behaviors, but only 56% were still abstaining from these behaviors 6
months after treatment had finished (Telch, 2001).
Overall this study was very effective. The researchers focused on one
disorder and one treatment, going into detail describing treatment and results.
These One weakness that this study had is that since the participants are all

17
women it may be difficult to generalize. Also the fact that they did not differentiate
the age groups could contribute to that.
A study by Klein (2013), they compared the use and effective of diary
cards for individuals’ self-monitoring with group dialectical behavioral therapy.
Dialectical behavior therapy is a branch of cognitive behavioral therapy. For
dialectical behavior therapy the focus is to help individuals change ineffective
patterns of behavior. The participants were those interested in this program as
advertised and were diagnosed with either Binge-eating disorder or Bulimia
Nervosa. In one condition these participants were asked to attend 15 two and a
half hour group dialectical behavioral therapy sessions and asked to watch
videotapes of any sessions that they missed. Participants in the other condition
were given a chart of skills and asked to keep track of which days they worked
on which skills. For both the diary card and the group dialectical behavioral
therapy, the results showed an improvement in binge-eating behaviors, but the
retention rate was higher for the dairy card technique.
In this study it was not defined what dialectical behavioral therapy was and
how it was different from cognitive behavioral therapy. Also, when the
researchers were describing the two conditions, they were very specific with the
diary cards (even gave us an example card). In the dialectical therapy, however,
the description was quite vague. The length of the treatment was described but
the specifics of the treatment were not. The background section was very
detailed and they made sure to address the implications of their study. This study

18
also addressed not only the disorders themselves but the underlying causes as
well.
Conclusion
As demonstrated through the studies evaluated above, the mindfulness
technique of Cognitive Behavioral Therapy can be used in many ways and in
many contexts with Binge-Eating Disorder. But this technique seems to be the
most effective when it involves a detailed program, with concrete actions to
perform in addition to the cognitive aspect. Although this technique is initially
effective, over time (and in the case of one study in a time as short as 6 months
effectiveness was almost halved) the benefits of this technique can diminish or
disappear. That is why the aspect of this technique where the individuals are
given the tools to succeed is so important
One of the important concepts of the mindfulness technique is that the
reduction of the behaviors of the Binge-Eating Disorder does not necessarily
mean weight loss. The goal of the mindfulness technique is to remove the
underlying issues that become obstacles to normal eating behaviors. So in order
for the mindfulness technique to be seen as effective, the improvement of the
binge eating behaviors is necessary but weight loss is not.
This treatment needs little additional research. It has demonstrated to be
an effective treatment in a variety of contexts, for both binge eating behaviors
and the causes that underlie those behaviors. This technique needs to be put
into practice. I propose a group therapy program (within groups it when this
technique seems to be most effective) that has a progressive program of skills

19
that are taught in weekly sessions so that eventually the individual can use these
skills without the aid of the group. However part of this program should a monthly
individual appointment to check in on the progress. This is essential because
without the encouragement and upkeep of the skills learned through the
Mindfulness treatment the effects of the treatment diminish rapidly.

20
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