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Binge Eating Disorder

Psychiatry - Classification & Disorders













Clinical Features and Epidemiology:

Binge eating disorder (BED) is characterized by repeated, persistent episodes of binge eating in the absence of the inappropriate compensatory behaviors seen in BN. According to DSM-IV diagnostic criteria, BED is defined by the consumption of unusually large quantities of food in discrete periods of time together with the experience of loss of control over eating. DSM-IV also specifies that binge eating in BED is associated with emotional distress, and must occur at least twice a week for six months to meet full diagnostic criteria (American Psychiatric Association, 1994). Currently a provisional diagnosis under the larger heading of EDNOS in the DSM-IV, BED is being proposed as a distinct eating disorder in the upcoming DSM-5 (American Psychiatric Association, 2010). In contrast to both AN and BN, BED is seen most frequently in middle-aged individuals, and is evenly distributed across gender and racial demographics, though there is some evidence to suggest that women may be more likely to present for treatment (Tanofsky, Wilfley, Spurrell, Welch, & Brownell, 1997; Wilson et al. 2007). BED is also distinct from the other eating disorders in that binge eating occurs in the context of general overeating as opposed to a setting of dietary restraint (Fairburn & Harrison, 2003). Because of the nature of its symptoms, BED has a strong association with obesity. Although present in approximately 3% of adults, the disorder has a higher prevalence among obese individuals (Grilo, 2002). In fact, BED is present in as many as 5-10% of patients seeking weight control treatment (Fairburn & Harrison, 2003). Because of its links to obesity, BED is associated with increased mortality and risk for numerous medical disorders, including hypertension, diabetes, respiratory illness, cardiac problems, and osteoarthritis (Wonderlich, Gordon, Mitchell, Crosby, & Engel, 2009). It is important to remember that individuals with obesity do not necessarily suffer from BED. Research has identified a distinct set of psychological characteristics that distinguish patients with BED from obese individuals who are not affected by the disorder. Compared to obese individuals without BED, those with BED report increased rates of depression, anxiety, and dissatisfaction with shape and weight similar to that seen in BN (Walsh, 2008; Yanovski, 1993). Individuals with BED also report a lower health-related quality of life, less life satisfaction, and more functional impairment than obese individuals without eating disorders (Wonderlich et al. 2009). Moreover, eating behavior studies have found that, when instructed to binge eat in a laboratory setting, individuals with BED eat more than their obese counterparts without the disorder (Yanovski, Leet, Yanovski, Flood, Gold, Kissileff, & Walsh, 1992; Goldfein, Walsh, Devlin, Lachaussée, & Kissileff, 1993; Sysko, Devlin, Walsh, Zimmerli, & Kissileff, 2007). Such evidence confirms the meaningful diagnostic and clinical distinction between binge eaters and non-binge eaters within the obese population. In preparation for the upcoming publication of DSM-5, there has been extensive debate about whether the current data available about BED support its identification as an eating disorder separate from the EDNOS category. In their review of BED, Wonderlich et al. argue that the consistent clustering of disturbed eating symptoms in affected individuals, together with the psychological distress, functional impairment, and significant rates of psychiatric comorbidity associated with BED, support its meeting the definition of illness (Wonderlich et al. 2009). In contrast to AN and BN, BED appears to have a shorter and more variable course. BED is associated with both high rates of treatment response and the possibility of spontaneous resolution of symptoms, but also possible symptom recurrence. Patients with BED are less likely to cross over to another active eating disorder than are individuals with AN or BN. Together, this evidence paints a portrait of BED as a variable, yet sometimes chronic disorder that often fluctuates over time.


11.2 Etiology

While researchers speculate that biological, psychological, and environmental factors con-tribute to the development of BED, as they do other eating disorders, the specifics of these risk factors for BED are still relatively poorly understood. Research does indicate that presence of obesity increases an individual’s likelihood of developing BED (Fairburn, Doll, Welch, Hay, Davies, & O'Connor, 1998). Additionally, there is preliminary data to suggest that BED runs in families, with heritability ranging between 0.39 and 0.57 (Hudson, Lalonde, Berry, Pindyck, Bulik, Crow, McElroy, Laird, Tsuang, & Walsh, 2006; Javaras, Laird, Reichborn-Kjennerud, Bulik, Pope, & Hudson, 2008). These substantial familial asso-ciations implicate a potential additive effect of genes on the development of BED. However, research has yielded mixed evidence regarding the preexistence of chemical or neurological abnormalities in individuals with this disorder. Though some early studies have yet to find any distinct neurochemical or hormonal anomalies among binge eaters, others tentatively associate BED with decreased levels of the hunger-stimulating hormone, ghrelin (Geliebter, Gluck, & Hashim, 2005). An individual’s development of BED may also be influenced by numerous non-specific risk factors for psychiatric disorders, such as parental depression and adverse childhood experiences (Fairburn et al. 1998).


11.3 Treatment of BED

Treatment of BED usually aims to help patients normalize eating behavior, with any weight loss achieved being secondary to the behavioral improvement. While excess weight clearly represents a significant medical problem for some individuals with BED, it is uncertain whether these individuals receive the same level of benefit (i.e., lasting weight loss) from behavioral weight loss treatment programs as non-binge eaters. Hence treatments that aim to improve binge eating behavior are typically recommended when BED is also present in the overweight or obese state (Wilson et al. 2007). Specialized psychotherapies have been shown to be helpful in addressing the psychological symptoms of BED. Both CBT and IPT are reliably effective in eliminating binge eating and reducing eating disorder psychopathology both in the short and long term. Although these specialized psychotherapies do not typically yield clinically significant weight loss, they do often prevent further weight gain by reducing or eliminating binge eating behavior (Wilson, Wilfley, Agras, & Bryson, 2010). Specifically, there is strong empirical support for the use of a form of CBT in BED. Adapted from Fairburn’s CBT for BN, this specialized treatment emphasizes recognizing and modifying unhealthy eating patterns (Fairburn, Marcus, & Wilson, 1993). CBT for BED is associated with a high treatment completion rate (approximately 80%), as well as remission from binge eating in 50% of patients, and general improvements in depression and other psychosocial impairments. IPT has been shown to be about equally as effective as CBT for treating BED in both the short and long term (Wilson et al. 2007). Finally, dialectical behavior therapy (DBT) is a specialized treatment that focuses on emotional regulation and gaining greater awareness of chaotic eating habits that characterize BED. While it does not boast as strong of empirical support as CBT and IPT, DBT seems to be a well-suited and durable alternative treatment for BED (Telch, Agras, & Linehan, 2001). However, the high cost of these specialized treatments, along with the limited availability of therapists who are adequately trained to perform them, has prompted researchers to investigate more accessible, cost-effective treatment options for BED. Wilson et al. found a mode of guided self help based on CBT (CBTgsh) to be equally as effective as IPT in eliminating binge eating in both the short and long term (Wilson et al. 2010). It is of note, however, that, neither CBTgsh nor IPT produced as much weight loss as did a separate behavioral weight loss treatment. In addition to psychotherapies, researchers have examined the efficacy of various medications in the treatment of BED (Bodell & Devlin, 2009). Consistent with evidence from combined treatment studies of BN, Devlin et al. found CBT to be more effective than fluoxetine as adjunct treatments to group behavioral weight loss treatment. While the addition of fluoxetine to CBT provided little if any improvement in binge reduction, the medication did decrease psychopathologies often associated with BED, such as anxiety, depression, and dietary restriction (Devlin, Goldfein, Petkova, Jiang, Raizman, Wolk, Mayer, Carino, Bellace, Kamenetz, Dobrow, & Walsh, 2005). Leombruni et al., on the other hand, found sertraline to effect a significant improvement in both binge behavior and binge frequency, as well as clinically significant weight loss for up to 24 weeks in women with BED (Leombruni, Piero, Brustolin, Mondelli, Levi, Campisi, Marozio, Abbate-Daga, & Fassino, 2006). Still other evidence from pharmacotherapy studies of BED suggests high and rapid rates of relapse, as well as simple noncompliance with extended open-label treatments (Wilson et al. 2007). The numerous characteristics of BED that distinguish it from AN and BN render it a subject of unique interest within the field. Because formal research on BED is in relatively preliminary stages, there is still much to learn about its etiology, symptomotology, and treatment. Future efforts would be well-directed towards studying the longitudinal course of the disorder, untangling the complex issues of its management, and further exploring biological and psychological factors that put individuals at risk for developing BED.

Conclusion



Eating disorders, including AN, BN, and BED are serious conditions in which significant disturbances in eating behavior are accompanied by distressing cognitions about body shape and weight. They are all illnesses with physical, as well as psychological manifestations. Once their symptoms are established, eating disorders may contribute to significant functional impairment, and are often very difficult to interrupt. Evidence-based treatments, including pharmacotherapy and CBT, are helpful in the treatment of BN and BED, but additional research is needed to establish empirically-supported treatments for AN, the eating disorder with the highest rates of morbidity and mortality.


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