Behind the scenes of Binge Eating Disorder: A clinical case study through the lens of the Psychodynamic Diagnostic Manual

Introduction: Binge eating disorder (BED) is characterized by recurrent binge eating behaviors involving the consumption of a large amount of food and a feeling of loss of control during the overeating episode. Patients with BED experience difficulty regulating affects and emotions, identity diffusion, immature defense mechanisms, and impairments in distinguishing between mental and somatic states. Although BED has only recently achieved diagnostic visibility, individuals with binge eating behaviors experience significant functional impairment, decreased quality of life, and increased risk of physical and psychiatric comorbidities. Methods: The present study aims at discussing, within the framework of the Psychodynamic Diagnostic Manual (PDM), the clinical case of a 25-year-old patient diagnosed with BED according to DSM-5-TR criteria, admitted to a specialized residential treatment. Attachment patterns were evaluated at intake through the Adult Attachment Interview (AAI) and reflective functioning and defense mechanisms were assessed using the Reflective Functioning Scale (RFS) and the Defense Mechanisms Rating Scale (DMRS) applied to the AAI transcripts. Personality patterns were assessed after the first month of treatment and at discharge, using the Shedler-Westen Assessment Procedure-200 (SWAP-200) applied to the Clinical Diagnostic Interview (CDI). At the same time points, the patient also completed the Eating Disorder Inventory (EDI-3), the Identity and Eating Disorders (IDEA) the Brief Mentalized Affectivity Scale (BMAS), the Multidimensional Assessment of Interoceptive Awareness (MAIA) and the Outcome Questionnaire (OQ-45). Furthermore the Comparative Psychotherapy Process Scale (CPPS) was used to evaluate the psychotherapy process. Results: Insecure-preoccupied and unresolved attachment patterns, along with low reflective functioning and immature defenses emerged. More importantly, changes were observed in the psychotherapy process, personality patterns and symptomatic impairment during and after treatment. Discussion: The findings underline the clinical value of a multidimensional approach within the PDM framework that promotes a comprehension that goes beyond the symptoms,but rather explores the full range of the patient’s functioning, including the emotional, cognitive, interpersonal, and social patterns, providing valuable implications for assessment and treatment interventions.