Single Case Study: Does EMDR Psychotherapy Work on Emotional Eating?

Eating Disorders

Eating disorders (EDs) are complex chronic illnesses with physical, social, and psychological ramifications. The thread of obsessive concern with food, weight and appearance, inappropriate eating behavior, and body image distortions runs through anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). The same thread runs through disordered eating—that is, problematic eating, where one eats “not out of physical hunger, but to soothe, numb, comfort, or avoid” (R. Shapiro, 2009), which is called emotional eating in this article. The National Institute for Health and Care Excellence (NICE, 2004) states that individuals who have EDs not otherwise specified should be treated in line with the treatment for the ED their symptoms most closely resemble. The ED most like EE is BED. Interestingly, the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5) does not list EE among any of the criteria for EDs, taking into consideration the increasing scale and serious consequences of this phenomenon, as pointed out earlier.

Psychogenic Overweight

According to Hart (2006), EDs can be divided into AN, bulimia, and psychogenic overweight, also known as comfort eating or emotional eating. Psychogenic overweight is here seen as a limbic disturbance, initiated as a sort of self-soothing to meet emotional uneasiness that cannot be integrated into the mentalizing functions of the prefrontal cortex. Instead, it will be expressed on a limbic level, that is, through somatization. This dissociation results in an inner feeling of emptiness, and this diffuse emotionality is replaced among other things by the consumption of food. The physiological and psychological needs are temporarily, although never entirely, satisfied. Eating gives a feeling of satisfaction because it activates the same structures as if you had social contact. According to Hart, sugar stimulates the release of opioids that again reduce both psychical and psychological pain. Research shows that mice, when separated from their mothers, cry less from separation if they drink water with sugar.

Emotional Eating

The reasons for the development of obesity are complex and caused by multiple factors such as neurobiological, genetic, cultural, psychological, social, and physical perspectives (R. Shapiro, 2009). This case study considers how emotional factors contribute to the problem and how the eating behavior is activated not by physical hunger but by an experience of a sudden hunger and craving for certain, typically high-fat and high-sugar “comfort”-food items (Campbell, 2011). The hunger is connected with upsetting emotions, and food is used as a primary source of comfort, coping, and emotional fulfillment, also called emotional eating.

Emotional Processes and Obesity

In their article entitled “Emotions and Eating Behaviour: Implications for the Current Obesity Epidemic,” Levitan and Davis (2010) consider the role of emotions in eating behavior and in the current obesity epidemic, focusing on two phenomena: the stress-related/emotional eating, which describes the use of high-caloric, highly palatable foods to deal with negative emotions, and overeating as a form of addiction. As a result of their review of several studies, they conclude that there is substantial evidence that emotional regulation plays a critical role in food consumption, and focus on emotional processes will be necessary if significant progress is to be made in addressing the obesity epidemic. They consider attachment theory, which focuses on normal and abnormal emotional regulation, to be an important approach. Of particular concern, too, is the fact that high-caloric, highly palatable foods, which are the most problematic in terms of weight gain and obesity, also have the strongest effect on alleviating negative mood states in most contexts and therefore have a critical influence on the EE behavior. Stress and anxiety are also strong contributors to EE, suggesting that multiple treatment approaches used in combination may be necessary for major progress to occur.

Avoidance of Feelings

Roth (1992) was among the first to link compulsive eating and perpetual dieting with deeply personal and spiritual issues that go far beyond food, weight, and body image. She shows how dieting and compulsive eating often become a substitute for intimacy. She shows why many people overeat in an attempt to satisfy their emotional hunger and why weight loss frequently just uncovers a new set of problems.

Maine (2000) addresses the issue and explains the impact of a cultural and economic system that undermines self-worth, self-acceptance, and self-control. EE is often approached in terms of how to avoid or get rid of the feelings. In the literature and in lifestyle programs, people are often advised to engage in distracting activities, such as taking a walk or a bubble bath, as a way to avoid EE, without the understanding of the self-regulatory function of the reach for food. Instead, the individual needs to develop the ability to tolerate uncomfortable feelings and to regulate the intensity of feelings (Matz & Frankel, 2004).

Albers (2009) introduces a collection of mindful skills and practices that help individuals to cope with these difficult feelings. This concept of mindful eating is probably helpful. However, mindful eating, distraction, or avoiding feeling do not address deeper emotional or traumatic experiences from the past, which in this study is considered to be the new and crucial approach for dealing with EE; this is essential in understanding the aim of this case study’s application of EMDR to EE. Whether EE stems from early traumatic material dysfunctionally stored in the memory system in the brain, to be explained later, or from a bad habit and unfortunate choice of soothing strategy, the hypothesis is that treatment has to be focused both on the past history (trauma), present triggering eating situations, and future affect regulation.

Affect Regulation

Disturbed eating patterns can in part be conceptualized as an affect management problem with roots in early attachment relationships. The style of our early attachments to primary caregivers is crucial in determining personality development, and affect regulation develops out of these early attachment experiences (Ainsworth & Bell, 1970; Bowlby, 1969, 1973, 1980; R. Shapiro, 2009).

Strategies for affect regulation are encoded, unconscious to unconscious, mother to infant, through psychoneurobiological mechanisms for coping with stress. A secure, healthy attachment facilitated by emotional attunement is critical to the development of affect regulation, and for people with EDs, “. . . food symbolizes the time when merger of mother with baby was or should have been a soothing experience” (Scholom, 2009, p. 116). The binge eater and the person suffering from EE lack an internal soothing presence to manage anxiety and turn to food, symbolic of the good mother. Affect regulation is expressed via the EE behavior, and defense mechanisms are forms of emotional regulation strategies for avoiding, minimizing, or converting affects that are too difficult to tolerate.

Traumatic Life Experiences and Obesity

These findings correspond to the Adverse Childhood Experiences (ACE) study (http://www.cdc.gov/violenceprevention/acestudy/), which is one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being. The study is a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente’s Health Appraisal Clinic in San Diego. More than 17,000 health maintenance organization (HMO) members undergoing a comprehensive physical examination chose to provide detailed information about their childhood experience of abuse, neglect, and family dysfunction.

The ACE study revealed that traumatic life experiences during childhood and adolescence are far more common than expected and that the impact of the trauma pervades the adult’s life, correlating with a wide range of problems, obesity being one of them (van der Kolk, 2014). According to van der Kolk (2014), trauma produces actual physiological changes, including a recalibration of the brain’s alarm system, an increase in stress hormone activity, and alterations in the system that filters relevant information from irrelevant information. Furthermore, trauma compromises the brain area that communicates the physical, embodied feeling of being alive. These changes explain why traumatized individuals become hypervigilant to threat and so often keep repeating the same problems and have trouble learning from experience; this is not a result of moral failings or a sign of a lack of willpower or bad character but is caused by actual changes in the brain.

Treatment of Trauma

According to van der Kolk (2014), one of the most important findings from treating trauma is the fact that “remembering the trauma with all its associated affect, does not, as Breuer and Freud claimed back in 1893, necessarily resolve it” (p. 194) and “research in contemporary exposure treatment, a staple of cognitive behavioral therapy, has similarly disappointing results” (p. 194). Fundamentally, there are three avenues of treatment to help reverse the damage, according to van der Kolk: “1) top down, by talking, (re-)connecting with others, and allowing ourselves to know and understand what is going on with us, while processing the memories of the trauma; 2) by taking medicines that shut down inappropriate alarm reaction, or by utilizing other technologies that change the way the brain organizes information; and 3) bottom up: by allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma” (p. 3).

One of the recommended approaches is EMDR psychotherapy, which is a way to help people revisit their traumatic past without becoming retraumatized and to allow effective memory processing and trauma solution. According to van der Kolk (2014), “clinical practice has always been a hotbed for experimentation. Some experiments fail, some succeed, and some, like EMDR, dialectical behavior therapy, and internal family systems therapy, go on to change the way therapy is practiced” (p. 262). These findings and considerations are the basis for the focus and selection of the method in this case study, which will be presented in the following section.

The Adaptive Information Processing Model

This model posits that the primary foundations of mental health disorders are unprocessed memories of earlier life experiences. It appears that the high level of arousal engendered by distressing life events causes them to be stored in memory in the limbic, nonverbal part of the brain with the original emotions, physical sensations, and beliefs. When these dysfunctionally stored memories are triggered, this unprocessed material often results in pathological or maladaptive responses to what might be an ordinary event. The flashbacks and intrusive thoughts of PTSD are examples of symptoms resulting from the triggering of these memories. Besides severe symptoms of PTSD, named big T traumas, a wide range of life experiences can be stored in a dysfunctional way, providing the basis for diverse symptoms that include negative affective, somatic, and cognitive responses in the present, which will be referred to as small t traumas (Solomon & Shapiro, 2008). The goal of EMDR psychotherapy is to access and process these memories and targeted experiences and transfer them from implicit and episodic memory to explicit and semantic memory systems. The originally experienced negative emotions, physical sensations, and beliefs are desensitized as the targeted memory is integrated with more adaptive information.

Eight-Phase Treatment Approach

EMDR therapy is an eight-phase treatment approach (F. Shapiro, 2001) composed of standardized protocols and procedures that facilitate a comprehensive evaluation of the clinical picture, client preparation, and processing of past events that caused the pathology, current disturbing situations, and future challenges. One of the components used during the reprocessing phases is composed of dual attention stimuli in the form of bilateral eye movements, taps, or tones.

The processing occurs in a systematic manner, including (a) client history and treatment planning; (b) preparation to include resourcing as needed; (c) assessment of the EMDR target memory; (d) desensitization using bilateral stimulation (BLS); (e) installation of the positive cognition (PC); (f) body scan; (g) closure of incomplete sessions, and preparation for session to end; and (h) reevaluation of the target at the subsequent session.

A justified hypothesis then is that EE and the eventual following obesity can be treated with an EMDR approach focusing on past trauma history, the deeper current emotional triggers that activate the disturbed eating behavior, and the future affect regulation.

Neurobiological Perspective

Cooke and Grand (2009) see EDs from a neurobiological perspective, which includes a basic understanding of appetite mechanisms and the effect of prolonged stress. EDs are usually preceded by a stressful life event or challenge that strains the individual’s coping resources, which again alters physiological and psychological systems. Through advances in neurobiology, a more dynamic understanding of how stress impacts ED symptoms is available. The hypothalamus controls many important functions, including appetite and the stress response, and is the main center for satiety and thermogenesis. This center reads the genetically predetermined set point for normal body composition and ensures that the body keeps in balance by effecting appropriate feedback mechanisms such as appetite and thermogenesis. One hypothesis is that EDs stem not only from a missetting or misreading of the set-point reference but also from problems in the malfunctioning of the feedback corrective mechanisms: “This results in an overshooting in obesity” (Cooke & Grand, 2009, p. 130). The limbic system—the emotional control center—controls the hypothalamus, and under stress, the limbic system sounds an alarm, which stimulates the hypothalamus to release corticotrophin-releasing hormone (CRH). CRH stimulates the pituitary gland to release adrenocorticotropic hormone (ACTH). In response, the sympathetic nervous system releases norepinephrine and epinephrine, which increase heart rate, respiration, and blood flow, to prepare for danger, igniting our fight-or-flight response. The symptoms are often dissociation, impairment in the ability of self-regulation and interactive regulation, little body awareness, little affect tolerance, and a general chronic emotional dysfunction. The limbic systems are activated and constantly alarming, making connections intolerable and hindering the capacity to learn new information. BED helps clients avoid distressing emotions, decreasing activation of schemata related to threats of safety, well-being, and self-esteem. EMDR can, according to Cooke and Grand, counteract the effect of prolonged emotional stress by decreasing activation of these perceived threats and thereby improve neurobiological functioning. Treatment needs to focus on stabilizing the limbic activation and teaching the client to regulate the affect in the triggering situations, and to develop self-regulatory abilities in the activities of daily life. The treatment consists of three steps: stabilization, processing trauma, and reintegration. With a better regulation of the overactivated limbic physiology caused by many interventions, and with the affect management protocol (York & Leeds, 2001) being one of the methods, the client can begin to deal with underlying traumas, losses, or wounds that are activating the EE behavior, thereby increasing frontal lobe activity.

Ego States and Dissociation

R. Shapiro (2009) presents interesting work treating AN and BED and has discovered the need to work with ego states and dissociation in bringing about change with this difficult population. Ego states refer to the fact that the personality is not

Dissociative strategies help the client to disconnect from painful feelings, body sensations, and self-experience generated by trauma and, by doing so, to form a new ego state holding the pain. EDs seem to mask underlying dissociative ego states that need to be integrated into the self. Within EMDR psychotherapy, these parts are conceptualized as dysfunctionally stored experiences unavailable to the corrective and healing powers of the prefrontal cortex (F. Shapiro, 2001). The purpose is to develop inner resources and to integrate fragmented parts of the self and thereby get to know the different emotional parts that fuel the dysfunctional eating behavior. It might be difficult, especially when the state is so dissociated that it does not experience the bodily consequences of its behavior. Ego state work is described by Watkins and Watkins (1998), Knipe (2012), and Schwartz (2001), and useful EMDR protocols are presented by Forgash (Luber et al., pp. 209–233).

Method

In the literature, two different protocols are recommended for the treatment of addictions: the craving extinguished (CravEx) protocol, an EMDR approach to treat substance abuse and addiction developed by M. Hase (Luber et al., 2010), and the desensitization of triggers and urge reprocessing (DeTUR) protocol, developed by Popky (Luber et al., 2010). However, neither of these protocols was explicitly designed to treat EE. Based on a review of EMDR and the treatment of EE and a conversation with Dr. Michael Hase (workshop June 1 and 2, 2015, Copenhagen), the DeTUR protocol was chosen as the one to apply in this case study. This protocol was developed to help clients reinforce positive coping by focusing on both treatment goals and relapse triggers. In the first part of the DeTUR protocol, the client focuses on the positive treatment goal. The client develops an image of what life would be like when changes are made. After enhancing this goal through the use of visual imagery reinforced by BLS, the treatment focuses on developing both internal and external resources to support change. Finally, each of the situations in the client’s life that trigger the unwanted behavior is treated. This protocol, combining a future positive treatment goal with systematic desensitization of triggers, has been recommended by Dr. Michael Hase when the issue has more to do with a behavioral addiction (EE) than substance abuse, where focus is on the addiction memory.

The DeTUR protocol had to be adjusted with some of the findings presented earlier in this article: