Metacognition in the Binge Eating Disorder
In order to develop and evaluate effective psychological treatments for Binge Eating Disorder, it is important to be able to reliably measure the characteristics underlying the development and maintenance of the disorder.
Binge eating, as has already been written in several articles, manifests itself in episodes of uncontrolled feeding, this means eating an objectively large quantity of food in a discreet period of time, all accompanied by a sense of loss of control. In BED, and often in other eating disorders, binge eating episodes are associated with guilt, disgust, marked distress and / or low mood. Studies conducted so far in the United States and Australia have found a prevalence of approximately 1-1.5% for Bulimia Nervosa (BN), 1.5-1.6% for Uncontrolled Feeding Disorder (BED), 0.4-0.5% for Anorexia Nervous (AN) and 3.2% for Other Nutrition and Food Disorders with OSFED Specification. The prevalence of binge applicants in the general community was between 7.2% and 13%,
In an attempt to better understand the complex symptom of the eating disorder of binge eating, numerous psychological models for binge eating have been proposed in the literature, many of which focused on the role of the limit of food quantity, low self-esteem, poor tolerance to suffering, on an overestimation of one’s body weight and shape, and on the specific metacognitions that invalidate the person with binge eating. It is therefore particularly important to evaluate and recognize the metacognitive beliefs that underlie the development and maintenance of binge eating, so that psychological treatment can be useful and effective over time.
Cooper, Wells and Todd (2008) identify three main types of metacognitive beliefs that work together to maintain binge eating: positive, negative and permissive beliefs about food. According to this model, an episode of uncontrolled nutrition is triggered by a distressing event that triggers a negative belief about the self as a person, such as: “I am not lovable” or “I am a failure”. Activation of these negative beliefs about oneself is accompanied by feelings of anxiety, depression or guilt. The model proposes that individuals with BED begin to binge as a means of coping with these unpleasant emotions and that binge reduces the intensity of short-term emotional states, which further reinforces positive beliefs regarding nutrition. Positive beliefs concern the perceived benefits of binge eating, particularly in reducing emotional distress (for example: “eating helps me cope with negative feelings”). Cooper et al. (2008) describe a conflict experienced by those who have positive and aversive beliefs about food, such as “eating will help me do it, but eating will also make me gain weight”. This conflict causes further anguish. As a result, permissive beliefs and negative (“are out of control”) beliefs about eating develop as a means of attempting to reduce this discomfort. Permissive beliefs are those that allow the individual to initiate or continue a binge eating episode, but do not address beliefs about their ability to control the urge to binge (for example: “I deserve to have a moment of pleasure like a binge”). Negative beliefs (“are out of control”), relate to the inability perceived by the individual to control himself in terms of resistance to food (desired object) and eat (and / or stop eating) once an episode of binge eating has started (e.g. example: “once I start eating I can’t stop”). The activation of permissive beliefs and negative beliefs trigger binge episodes: they allow the person to start a binge and / or to feel unable to avoid starting a binge. In turn, the act of binge eating further activates negative self-beliefs (for example: “I am weak”) and aversive thoughts about eating (for example: “I will become fat”), which lead to further episodes of binge eating. The cycle is further strengthened when binge eating behaviors reactivate and / or further reinforce positive and permissive beliefs, and negative beliefs about not controlling the act of eating while eating. Therefore, Cooper et al. (2008) suggest that it is the combination and interaction of fundamental beliefs (negative self-beliefs) and the three types of metacognitive beliefs (positive, permissive and negative beliefs about eating) that maintain binge eating behavior.
In recent studies by Burton et al. (2018), The revised short-form of the Eating Beliefs Questionnaire: Measuring positive, negative, and permissive beliefs about binge eating and Beliefs about Binge Eating: Psychometric Properties of the Eating Beliefs Questionnaire (EBQ-18) in Eating Disorder, Obese, and Community Samples, the researchers investigate the metacognitive beliefs that underlie binge eating, using the clinically tested questionnaire on food beliefs (EBQ), which investigates eighteen nutrition items (EBQ-18) and is divided into the three subscales (negative, positive and permissive beliefs about eating). The tool is based on metacognitive theory and the cognitive model.
The eighteen main beliefs are:
Such metacognitive beliefs about food and food thinking are relevant to maintaining uncontrolled eating behavior and converge with the symptoms of eating disorder, emotional regulation, mood and anxiety. The assessment of the beliefs that EBQ makes is useful and valuable for both clinicians and researchers who want to measure key maintenance knowledge, and how these shift during the course of the intervention with individuals who eat uncontrollably.
Spada et al. (2016) investigates how negative metacognitions about wishing thinking preach the severity of binge eating in women. They also checked for possible connections with age, self-reported body mass index (BMI), negative mood, irrational food beliefs and craving (the urge to ..), showing that negative metacognitions about wishful thinking predict the severity of binge eating. Why should negative metacognitions about wishful thinking be a predictor of the severity of binge eating? The probable explanation, in line with existing theoretical understanding and empirical results, is that such metacognitions guide the perseverance of desiring thought (Caselli & Spada, 2015). In other words, the activation of these metacognitions indicates that there is no possibility of actively controlling intrusions related to wishing thought (MDTQ-2) or the cessation of wishing thought (MDTQ-1). This will likely lead to perseverance of wishful thinking, escalation of craving and consequent negative feeling, as the desired goal (eating) is repeatedly worked out but not achieved, having the option of eating as the main way to achieve emotional self-regulation. (Caselli & Spada, 2010; 2011; Spada, Caselli & Wells, 2013; Spada, Caselli, Nikčević & Wells, 2015). In support of this vision,
The evaluation of negative metacognitive beliefs on the desire for food thinking can have utility and feedback in the clinical setting. Evidence suggests that although CBT is an effective treatment, recurrence rates remain moderately high (e.g. Brown & Keel, 2012). The CBT model focuses treatment on changing core beliefs and their content (core belifes, self-esteem beliefs and irrational food beliefs), as well as extreme diet moderation. The treatment of metacognitions, on the other hand, addresses a group of higher-order beliefs (metacognitions) involved in the control and regulation of cognition (Wells, 2013). In particular, by addressing the metacognitions of the uncontrollability of desiring thought, a new dimension of understanding can be reached of the mechanisms that drive the escalation of craving, the impulses for food and consequently the frequency of binges. The interventions could also actively target the interruption of thought about desire and modify the associated metacognitions. This could be done by supporting the patient in identifying their metacognitive processing, obtaining flexible control over attention and thinking style, and developing new processing plans. The intervention takes place through the application of Metacognitive Therapy Techniques such as Attentive Training (ATT), Detached Mindfulness, Refocusing of Situational Attention (Wells, 2009), as well as the Visuospatial Tasks (May, Andrade, Panabokke and Kavanagh, 2010) ,
Quattropani et al. (2016) invite us to pay attention to the patient’s executive functions and psychological needs, useful for metacognitive treatment. In fact, the authors explored the association between metacognitions, executive functioning, psychological needs and eating behavior. The results of an increasing number of studies have suggested a link between obesity, poor cognitive performance and deficit in executive functioning (Sorensen, Sonne-Holm, Christensen and Kreiner, 1982). Previous studies have focused on the association between dysfunctional metacognitive processes and eating disorders such as Anorexia Nervosa – AN (Cooper, Grocutt, Deepak & Bailey, 2007), Bulimia Nervosa – BN (Sassaroli et al., 2007) or Binge Eating Disorder – BED (Harltey, 2013), confirming the correlation.
Specifically, Quattropani et al. (2016) identified correlations between dysfunctional metacognitions such as: negative beliefs about concern about uncontrollability and danger, the need to control certain types of thoughts, a general psychological mismatch and consequent affective problems, present in people with a level of low education and high risk of eating disorder risk. This difference, the authors say, may be due to slightly impaired metacognitive and executive functioning and further speculate that this condition may not only have influenced academic performance and success, but could have a central role in eating behavior, reducing control in food intake.