Objective Clinical Change of Cognitive-Behavioral Strategies for Binge Eating Behavior: Case Report

The binge eating behavior in addition to affecting physical health generates psychological discomfort. The aim of this research was to evaluate the objective clinical change of an intervention with cognitive-behavioral strategies to modify binge eating and its associated variables. In this case report, two women (19 and 20 years old, respectively) diagnosed with binge eating disorder took part who signed an informed consent form and answered a battery of validated questionnaires in the Mexican population, this in the Pretest and Posttest phases to assess binge eating, body dissatisfaction, self-esteem, anxiety and depression symptoms, and quality of life. It was found that through the calculation of the objective clinical change, a favorable change between 50% and 80% of the assessed variables was found. It is concluded that the intervention using cognitive-behavioral strategies had a positive effect on binge eating and its associated variables. However, due to the nature of the study, it is not meant to generalize the findings, a case-control study would be neces-sary to strengthen these data to the medium and long term.


Introduction
The world today and Mexico in particular, experience a high prevalence of obesity. According to the preliminary results of the Mexican National Health and Nutrition Survey (ENSANUT-2018; Instituto Nacional de Salud Pública [Mex-Psychology ico's National Institute of Public Health, 2018]) which show a rising trend over the years, 74.9% of the Mexican population > 20 years old (74.9% of women and 71.2% of men) are overweight or obese people. One of the universally used indicators in the clinical research field to determine excess weight is the body mass index (BMI), since it is an inexpensive and easy-to-perform method. The BMI is calculated by dividing a person's weight in kilograms by the square of his or her height in meters. If a BMI is ≥ 30, it falls within the obesity range; frequently subdivided into categories: Class 1: BMI of 30.0 to 34.9; Class 2: BMI of 35.0 to 39.9 and Class 3: BMI equal or greater than 40.0 (World Health Organization [WHO], 2020). A high BMI is a risk factor for the development of comorbid conditions associated with a more complex clinical management and treatment.
BED's main criterion is the binge eating characterized by the consumption of unusually large amounts of food once a week for less than a 2-hour period with a three-month recurrence duration. BED is also characterized by a loss of control over the foods consumed consisting of eating at a faster speed than normal without experiencing true physiological hunger. In addition, after a binge eating episode, there is an important feeling of guilt among other feelings such as depression, shame or disgust. All the foregoing put a BED patient's overall health at risk (DSM-5, APA, 2013). Some BED treatments focus on weight loss (Katz et al., 2017), but it observed a rebound effect, gaining back all of the lost weight within the following year (Aguilar et al., 2015). Hence, a BED treatment must mainly address the eating psychopathology and not the excess weight condition; about this, treatments including self-regulation of eating behavior have been proposed (Katz et al., 2017).
Treatments for binge eating or BED can be: 1) pharmacological with antidepressants or appetite suppressants, despite some negative consequences which prove their effectiveness in the short-term only (Cuadro & Baile, 2015); 2) psychological treatments aimed at achieving a psychological adjustment, modifying the cause of the psychopathology to avoid complications and prevent relapses, Psychology therefore, the only post-treatment outcome should be sustained re-learning in favor of psychological health. In this regard, ample effectiveness of the cognitive-behavioral therapy (CBT) has been proven equally for ED (Johnsen & Friborg, 2015). Furthermore, there is specific evidence of the positive effect of such therapy for BED, as well as the suggestion that results are enhanced when therapy is individual (Cuadro & Baile, 2015).
In this regard, despite the effectiveness of Self-Help CBT (Fairburn, 2017), patients are at a high risk of interrupting the treatment because self psycho-education requires a very high motivation; whereas considering 3 rd generation CBT techniques have still produced weak results (Iacovino, Gredysa, Altamn, & Wukfkey, 2012), this being the case and with the pursuit of offering a different format to treat binge eating and BED with simple cognitive and behavioral strategies, as well as an analysis beyond descriptiveness, the aim of this research was evaluating the objective clinical change of an intervention with cognitive-behavioral strategies to modify binge eating behavior and its associated variables.

Patients Identification and History of Problem
Participants requested support to eating behavior laboratory of University to treat their eating behavior because it was affecting their psychological well-being (e.g., feelings of sadness, worry, low self-concept), which became reason for inquiry. Participant 1 (hereinafter referred to as Pa1), 19-year-old university student, with a body weight of 97.8 kg and a 40.2 BMI. Participant 2 (hereinafter referred to as Pa2), 20-year-old with a body weight of 101.2 kg. Through the interview for Eating Disorder Diagnosis IV (IDED-IV; Kutlesic, Williamson, Gleaves, Barbin, & Murphy-Eberenz, 1998) and a 24-hour food reminder, a specialist diagnosed both participants with BED, based on DSM-5 criteria (APA, 2013). In general, the participants stated that in the last year, they had had four (Pa1) and three (Pa2) binge eating episodes per week respectively, in other words, they ate unusually large amounts of food compared to what any person could possibly eat under the same circumstances, experiencing a loss of control as well as hiding to eat until they felt unpleasantly stuffed, in addition to the fact that they both fasted on an irregular basis as a compensatory behavior. According to the frequency of binge eating episodes, Pa1 is identified as moderately severe and Pa2 as mildly severe BED.

Selection of Adequate Treatment and Establishment of Therapeutic Goals
The authors based on the participants characteristics, decided to design an intervention program with cognitive-behavioral strategies to modify binge eating and associated variables with an experimental design. In an ad hoc plan, the protocol and its procedure were explained to them and they accepted participating in study and signed the informed consent form, which is based on

Measures
In the Pretest and the Posttest phases as well, the participants answered a battery of questionnaires to measure the following dependent variables:

Results: Evaluation of the Effectiveness of the Intervention
1) Descriptive terms based on total scores both in the pre-test and post-test phases, to characterize the sample.
2) Objective clinical change (OCC) was calculated using the formula proposed by Cardiel (1994), which stipulates that a ≥ 20 value is a significant change indicator to show or not a positive effect after intervention.
3) Personalized analysis of the two participants.

Pretest Assessment
In higher risk, in other words, this body condition could contribute to develop or maintain medical or psychological obesity-related comorbidities.
Regarding the dependent variables, it is observed that both participants were above the median binge eating subscale (Me = 33) scores; moreover, they exceeded the BSQ CP ≥ 110; as for self-esteem, Pa1 had a low self-esteem and Pa2's self-esteem was moderate; regarding depression symptoms, these were mild for Pa1 and moderate for Pa2; whereas anxiety symptoms were severe for Pa1 and moderate for Pa2. As for total quality of life and its dimensions, these were below the reference value for the Mexican population in relation to the WHOQOL-Bref, except Environment for Pa2.
Findings provided evidence indicating that the psychological health (See Ta-ble 1) of the two participants with BED was affected (Pretest Phase).

Participant' scores of three of the assessed variables between the Pretest and
Posttest phases are shown in Figure 1. As it can be seen with the subscale BULIT (binge eating), Pa1 went down 14-points, whereas Pa2 went down 16-points in the Posttest phase. As for body dissatisfaction which was assessed with the BSQ, it can be observed that Pa1 went down 82-points and Pa2, 50-points. Whereas higher scores for self-esteem assessed with the RSES can be observed, Pa1 went up 4-points and Pa2, 1-point.
In Figure 2, the scores of the two mood variables of the Pretest and Posttest phases can be observed. Regarding depression symptoms which were assessed Psychology

Objective Clinical Change after the Intervention
On the other hand, with the purpose of assessing the OCC (between the Pretest and Posttest phases), the formula proposed by Cardiel (1994) was used and the results can be seen in Table 2. In Pa1's case-in 10 of the assessed variables-an OCC was observed in eight (80%; binge eating, body dissatisfaction, anxiety symptoms, total quality of life, physical and psychological health and environment) and did not any change in 20% of variables (depression symptoms and social relationships); whereas Pa2 showed OCC in five variables (50%; binge eating, body dissatisfaction, total quality of life, physical health and social relationships), and did not show any OCC in self-esteem, depression and anxiety symptoms and remained stable in psychological health and environment.

Personalized Analysis of the Two Participants
Finally, when performing a more personalized analysis, the participants reported a decrease in their binge eating frequency: Pa1, from 4 to 0 and Pa2, from 3 to 0. Nevertheless, attention is drawn to the fact that when taking the 3-month duration criterion for BED symptoms into consideration according to the DSM-5 (APA, 2013), the participants continued meeting the diagnosis criterion, despite the drop in the frequency of the number of binge eating episodes, given that the criterion is three months and at the time of the post-assessment, two months and 3 weeks had gone by. However, during and at the end of the intervention, both participants reported a momentary and general feeling of well-being, since they did not gain weight and were able to achieve the eating behavior objectives. Considering the elements of intervention regarding the development of behavioral goals (specific and measurable in terms of behavior), the following examples of same is presented herein: Pa1 "I will establish specific times to eat my meals with alerts on my cell phone". Pa2 "I'll eat less chocolates and keep a record". Psychology As for identification of incongruent beliefs: Pa1 said "…I can't always eat healthy food or give myself time …"; Pa2 said, "I'll go to the store and buy everything I see", this type of thoughts are conducive to incongruent behaviors and therefore, self-questioning helped them modify incongruent beliefs and achieve objectives. Now, regarding the identification of conditions that trigger binge eating episodes, an example of each participant is provided herein: Pa1, "…It was about 6 p.m. and I was alone. I felt anxious and decided to open the refrigerator and look for something to eat. I thought that I would only eat a little, but started binging, however, I realized what was happening and stopped eating…". The participant mentioned that she felt happy for being able to stop the binge eating episode, and at the same time she experienced a pleasant sensation with what was happening; Pa2, "…It was 9 p.m., I was in my bedroom and a family argument made me feel angry and desperate. My first thought was to eat something, and I went out to buy three bags of potato chips and an energy drink. When I got back home, I locked myself up and started eating, but when self-questioning my feel-ings, hunger vs. anger, I stopped eating and this calmed me down and I felt happy".

Discussion
The general aim of this research was evaluating the objective clinical change of an intervention with cognitive-behavioral strategies to modify binge eating behavior and its associated variables, which included psychoeducation on eating behavior and body dissatisfaction, training on identification of binge eating circumstances, consequences and maintainers, as well as training on development of behavioral objectives and identification of congruent and incongruent thoughts and behaviors associated with binge eating, as well as self-questioning.
Specifically, as for the intervention and regarding OCC which is deemed a more specific and individualized analysis, the findings herein reflect positive results in 80% and 50% of the assessed variables (binge eating episode, body dissatisfaction, self-esteem, depression/anxiety symptoms and quality of life) of the two participants, respectively. This data is similar to the data reported by García-Marín, Antón-Menárguez and Martínez-Amorós (2016) in an intervention with cognitive behavioral techniques (psychoeducation, breathing, stimulus control and self-instructions) with a participant with similar characteristics to the participants of this study, such as gender, age (19 years old), occupation (university student) and excess weight condition (morbid obesity) which documented a reduction of binge eating episodes, anxiety and depression symptoms an increased self-esteem.
Regarding body dissatisfaction, it is important to highlight that, although this is not a diagnostic criterion of BED, it affects patients with this eating psychopathology (Cuadro & Baile, 2015;López-Aguilar et al., 2017;Naumann et al., 2018). In this regard, body dissatisfaction has been found to be a significant binge eating predictor (López- Aguilar et al., 2010), the scores reported by the participants of this study were way above Mexican population's CP and reduced substantially in the Posttest, specifically, one of the patients achieved an almost 90% of positive change. These findings show that a reduction of this characteristic in patients with BED is possible and contributes to their psychological health, considering that body dissatisfaction may work as a trigger or maintainer of a binge eating episode.
As for quality of life and its dimensions, a moderate improvement was found in this construct, similar results were reported in a meta-analysis, both for quality of life in general as well as life related to health. It was further indicated that findings were better in individual interventions (Linardon & Brennan, 2017).
Recently, linear relationship between BED and quality of life was not found because depression moderates this relationship (Singleton, Kenny, Hllet, & Carter, 2019). In this study after the intervention, an increase in the quality of life was observed.
The psychological treatment is a professional intervention aimed at develop-Psychology ing adequate skills to cope with different alterations, both psychopathological as well as non-psychopathological and under this logic, the participants of this study, achieved learning the design as well as achievement of the behavioral objectives, identification of beliefs and incongruent behaviors, as well as the identification of conditions that trigger binge eating episodes and their self-questioning.
There is documentary evidence that CBT, its techniques and strategies are based on scientific evidence and therefore have yielded positive results for psychological alterations in general, and for ED, specifically for BED (de Jong, Schoorl, & Hoek, 2018); this study adds to said results.

Conclusion
The objective clinical change allows to conclude that this intervention based on cognitive and behavioral strategies had a positive effect on the frequency of the binge eating behavior, as well as a reduction of body dissatisfaction, increase of self-esteem, reduction of anxiety symptoms and a moderate improvement in the participants' quality of life which consequently lead to a momentary and general well-being. Psychopathologies are complex health issues, due to which treating same requires an interdisciplinary team, therefore, these findings could benefit from the contributions of other health disciplines, so that, instead of performing a secondary prevention, a primary prevention is performed. Accordingly, in obesity and BED cases, an intervention mainly focused on the eating psychopathology aside from simultaneous treatment of obesity is necessary. These results enable us to hypothesize that, the development of-specific and achievable behavioral objectives in the short term-and the identification of congruent and incongruent beliefs and behaviors, as well as the identification of conditions that trigger binge eating episodes and self-questioning, may also be the basis for universal, primary prevention in ED, notwithstanding the fact that behavioral records could be included to analyze specific behaviors.
The results of this study are not meant to generalize, considering that the participants in this intervention have certain characteristics and the program must be tried on participants with different characteristics (e.g., age, gender and level of education). What is clear is that changes were not generated randomly and correspond to a specific methodology which may be susceptible to replication. However, in future research, broad samples of cases and controls and mediumand long-term assessments must be used to assess learning throughout time.