Wendy Oliver-Pyatt, MD, FAED, CEDS, joined us for an interview on her book Questions and Answers About Binge Eating Disorder: A Guide for Clinicians. What follows are our questions in italics, and her thoughtful responses.
You opted to use a Q & A format for Questions and Answers About Binge Eating Disorder: A Guide for Clinicians. What guided this decision?
The decision was based on our hope that an easy to use guide would provide a foundation for understanding Binge Eating Disorder (BED), and could improve the quality of life of those experiencing this condition. It was essential that we elucidate critical realities about the treatment of BED for a variety of clinicians. Certainly, there is confusion and lack of clarity even within the field of eating disorders about certain elements of treatment (for example, should weight loss be a goal of treatment). For clinicians, including medical doctors, who are not familiar with eating disorders, but who encounter the condition far more than they may realize, it was essential that we provide a simple, straightforward way to answer questions relevant to BED. Binge Eating Disorder is the most common of all forms of eating disorders and an under-recognized, over looked, and complex condition, that many practitioners encounter and, therefore, “miss” the diagnosis. Sadly, these “missed” cases of BED are frequently prescribed behavioral weight loss and go on to a life of unhealthy weight cycling. We wanted to create a book that would allow any practitioner, (seasoned or not seasoned) who may potentially encounter patients with BED, to have available a quick and simple resource that increases understanding, communication, and effective, well thought out treatment planning. It was also important, in developing the questions, to consider the most commonly misunderstood aspects of BED, and to give clinicians a strategy that could be easily implemented to explore the possibility of this diagnosis in previously undiagnosed cases.
What behaviors need to be present for a diagnosis of Binge Eating Disorder?
The behaviors associated with Binge Eating Disorder are described in the DSM-5. Interestingly, Binge Eating behavior was identified by Albert Standard, a pioneering psychiatrist and researcher who described three patterns of eating including binge eating, night eating, and eating without satiation. All of these patterns are captured in the DSM-5 in the first part, which characterizes a quantity of food (far more than normal) and quality of eating (feeling out of control while eating). Of these two, helping a patient talk about the latter experience of feeling out of control can be the foundation for a meaningful and delicate conversation that can be a relief to the patient and the very beginning of the recovery process. The DSM-5 does a nice job of providing descriptors of behavior associated with binge eating (eating fast, eating beyond feeling full, eating large amounts even when not hungry, eating alone, and feeling emotionally distressed after a binge). There is a frequency of binge eating necessary in order to make the diagnosis of Binge Eating Disorder and also the qualifier that the patient must be “very upset” by the binge eating. Individuals with Binge Eating Disorder do not “undo” the behavior in the extreme ways seen in Bulimia Nervosa. However, it is important to realize that despite the fact that the BED patient does not engage in this severe “undoing,” he/she is still suffering and dealing with a complex neurobiological/psychiatric condition.
Given current understandings of neurobiology, what are some of today’s hypotheses regarding causes of BED?
It is important for individuals with BED and their providers to understand that those who suffer with BED are not simply lacking self control. This is not a case where telling the patient to just try harder and pull his/her bootstraps up! The exact cause is not known, but the first hypothesis involves the impulse-control related areas of the brain and brain reward centers, with the theory that the area of the brain that controls the impulses around the reward associated with eating is diminished, and the reward itself is experienced more intensely. There is functional MRI research that supports this hypothesis. Another hypothesis involves Neurotransmitter Dysregulation, namely dopamine dysregulation that can create an intense sensation of “wanting” food. Individuals with BED were found to often have specific genotypes that enhance the “reward” experience of dopamine. Finally, the endogenous mu-opioid signally theory espouses that endogenous opioids convert sensory stimuli into processes that generate or enhance “liking” of a particular food and feeling pleasure from eating.
It is important to note that not any one theory that we know for certain is the actual cause, or that all or some of the aspects of these theories may be at play with patients experiencing BED.
Can you please tell us about the goals in successful BED treatment and recovery?
It is important to realize that recovery is a process, and also becoming recovered is possible. Recovery from Binge Eating Disorder involves the patient developing a relationship with food that allows them to nourish their body in a healthful, mindful way. Recovering allows the journey toward both an awareness of eating and a pathway of genuine, mindful pleasure associated with eating (no — binge eating is not fun; in fact, when you talk with patients you come to realize that binging in BED is experienced as dissociation, and our patients experience an incredible level of distress around binge eating). I think that goals involve also addressing any underlying co-occurring condition that may make cessation from binge eating more difficult or make the drive to binge eating more intense. Recovering involves the development of an attitude or mindset that involves compassionate self-awareness, enhanced self-care, and also in an ideal situation, an increased sense of value, purpose, connection, and meaning in one’s life.
What should professional providers avoid when treating an individual with BED?
Professional providers should avoid over-simplifying the causes and treatment of Binge Eating Disorder. Providers should avoid prescribing behavioral weight loss, should not assume that recovering will be associated with weight loss (if the person has gained weight as a result of binge eating), and should not make the treatment about weight. Binge Eating Disorder is a complex condition and providers must be both compassionate and knowledgeable. It is important that providers not make comments or treatment suggestions that induce shame around binge eating or weight. Providers should know what weight cycling is and not be a part of the problem of exacerbation of weight cycling.
Can you please explain why an increase in reported symptoms during BED recovery may actually be a sign of improvement?
BED can be a very isolating and may be associated with a tremendous amount of shame. Like any problem any of us deal with, becoming aware of our issues, and facing our problems is essential to dealing with them successfully. Isolation, when faced with any form of mental health issue, is generally not a helpful thing. Describing the problem of Binge Eating from a stance of self-compassion is a powerful experience. Sharing the problem with providers, family, and friends can be a huge relief, can help build a foundation of support, and is a sign that the patient is understanding the struggle they are experiencing with more awareness and less shame.
Please share your words of hope for recovery from BED.
In the darkest moments of binge eating, perhaps alone in a dorm room, alone in a home, or driving alone in a car, shame, despair, a sense of isolation is blurred together with a state of dissociation that somehow also activates some level of euphoria, pleasure, or release. The out of control nature of this experience cannot be understated, nor can the distress, and agony of “waking up” from a binge. It is hard to fathom recovery when one is wrapped up in this behavior. The essential first steps of recovery start with knowing that there is a name for this behavior, and that this behavior is not your fault, that there is a neurobiological component (again, not your fault) and there are strategies one can start taking right away to leave this darkness and start to enter the light. Discovering mindful eating is the blessing in disguise for individuals who have lived with this condition and tried dieting and behavioral weight loss. Learning how to eating mindfully is a huge task, but is none the less vitalizing and validating on levels that go far beyond one’s relationship with food. The condition itself is not something I or anyone wants to experience. The pathway to recovery, though challenging, presents the opportunity for growth along many domains, including the domains of self-awareness, self-compassion, and also having a voice and becoming a self-validating person. Recovery also often involves a higher-power component and a component that speaks to the condition of self-acceptance, self-respect, and treating oneself with dignity, care, and respect.
About the author:
Dr. Wendy Oliver-Pyatt received her specialty training at New York University-Bellevue Hospital in New York City, where she served as Chief Resident. She has held faculty positions at New York University, Albert Einstein School of Medicine and University of Nevada School of Medicine. Dr. Oliver-Pyatt was the State Medical Director for the Division of Health for the state of Nevada. She has developed innovative eating disorder treatment programs known for integrating compassion with science including Center for Hope of the Sierras, Oliver-Pyatt Centers, Clementine Adolescent Treatment, and Embrace, the BED treatment program at Oliver-Pyatt Centers.
She is a clinician, educator, and advocate – having served as the AED Advocacy Committee Chairman, and Co-author of AED Guidelines for Obesity Prevention.
Wendy served on the Joint Commission on Accreditation of Health Care Organizations Technical Advisory Committee and has given frequent presentations at national and international eating disorder conferences.
Throughout her career, she has focused on promoting awareness of the impact of the trauma of weight stigmatization and the health risks associated with weight cycling. Dr. Oliver-Pyatt has received Senatorial recognition for her work as a psychiatrist and commitment to the mental health community.
Wendy also spent several years as Chair of the Board of Directors of the Binge Eating Disorder Association and also served on the BOD for the International Association of Eating Disorders. She is a Fellow of IAEDP and also a Fellow of the Academy for Eating Disorders. She is the mother of four children and gets great joy out of seeing her children become young adults. Wendy is known for her warmth and her unbridled conviction to help and encourage others to live their life with passion and compassion for self and others.