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Binge-eating disorders in the Arab world and the Netherlands

Psychologist Bernou Melisse was shocked at the long waiting lists in the Netherlands for people with binge-eating disorders. The problem was not yet on the map in Saudi Arabia. She therefore decided to study how people suffering from binge eating can be helped better in their own region of the world. PhD defence 13 September.

Eating too much and too quickly: binge-eating is something that a lot of people suffer from. It is globally most common eating disorder, yet the one about which we know the least; it often goes unrecognised or is treated incorrectly, leading to a much longer duration. In comparison with other eating disorders, binge eating is the most frequent eating disorder across all strata of society. The condition has only been included in the DSM, the manual for the classification of psychiatric disorders since 2015.

Bernou Melisse wanted to improve the treatment and diagnostics of people with binge-eating disorders in Saudi Arabia and the Netherlands. ‘For both countries I wondered where the gaps were and where I should  focus my research.’ 

Have I got an eating disorder?

How did Melisse come to focus on Saudi Arabia? ‘I wanted to do something new and exciting,’ she says. The vacancy for a partnership with Erasmus University Rotterdam  held the promise she was looking for: Psychologists wanted for an international team (Dutch, British, Pakistani) to set up the new Clinical Psychology programme at a major women’s university in Riyadh in Saudi Arabia. ‘During those 3 ½ years after lectures on eating disorders students would come along with questions: “Have I got an eating disorder? What should I do?” I discovered that there were no diagnostic questionnaires in Saudi Arabia, no support for diagnosing eating disorders and no specialist treatment centres.’ 

Translating, adapting culturally and validating questionnaires

Melisse conducted most of the research besides doing a job, and outside working hours. ‘I initiated the research in Saudi Arabia myself and decided to translate existing diagnostic questionnaires on eating disorders and body dissatisfaction due to eating disorders, culturally adapt them and make them scientifically valid.' She is the first person to introduce the use of questionnaires in Saudi Arabia and is one of the first to study these eating disorders. ‘My research showed, among other things, that the disorder is most common in Gulf countries where industrialisation is most rapid, as well as among Saudis with a higher BMI index and greater body dissatisfaction. Among the 2,700 Saudi participants, highly educated women were overrepresented, though. But westernisation does not seem to have an impact.’

Bernou Melisse with a binge-eating disorder patient during one of her sessions.

Slimming makes you more susceptible to binge eating  

Back in the Netherlands, Melisse started working in a specialist treatment centre for eating disorders. Patients with a binge-eating disorder have generally already had the condition for 25 years because they have been incorrectly referred, for example to a dietician. A binge-eating disorder often goes hand in hand with obesity, which means people tend to focus on weight management, says Melisse. When you eat below your energy needs or eat irregularly or too little, you get extra cravings. Compare it to holding your breath underwater: when you surface, you start gasping for breath. Losing weight makes you more susceptible to binge eating, which puts you in a downward spiral. 80% of people who do not eat enough binge eat and then gain weight. 

‘In the time of a regular therapy session we can treat four people with guided self-help, so you can treat more people with the same treatment  capacity.'

Self-help module with guidance from an expert

There are waiting lists for specialist eating disorder treatment, including a psychological approach. Melisse therefore wanted to treat more patients in a shorter time, and with positive results. With treatments based on the most recommended cognitive behavioural therapy (CBT-Enhanced) Melisse developed a self-help module that includes guidance from an expert. She was the first person worldwide to research an online variant of CBT-E. Clients log in daily, and do assignments, the results of which are sent to their practitioner, with whom they have a video call appointment once a week. They then discuss obstacles and are given feedback on their assignments.' Within the time of a regular therapy session, we treat four people with guided self-help, so you can treat more people with the same treatment capacity.'

80% no longer have eating disorder symptoms and 50% no longer have binge-eating issues

‘The effectiveness of CBT-Enhanced treatment was compared with a waiting list, because you want to know if there is any natural progression in the symptoms. In the last four weeks of the 12-week treatment, 80% of clients no longer had eating disorder symptoms and 50% no longer binge ate. In regular face-to-face treatment, this is about 65-70% and 48%. The symptoms remained the same for those on the waiting list, indicating that the treatment is effective. ‘My ambition is to offer online CBT-E unsupervised in Saudi Arabia and the Gulf countries as well as to other sufferers who don’t have access to therapy, who are not insured or where there is a shortage of therapists. The good news is that a regular CBT-E training recently started for therapists in Saudi Arabia.’ 

Banner: Bernou Melisse in front of the university building in Riyadh, Saudi Arabia

Melisse, B., van den Berg, Jonge, M. d., Blankers, M., van Furth, E., Dekker, J., & de Beurs, E. (2023). Efficacy of Web-based Guided Self-help Cognitive Behavioral Therapy- Enhanced for Binge Eating Disorder: a Randomized Controlled Trial. Journal of medical Internet research, 25, e40472. 

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