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Day # 148: Binge-Eating Disorder

Today we will continue our current theme of eating disorders as we discuss binge eating disorder (BED).

Today's Content Level: Beginner and Intermediate

Introduction 1

  • Binge-eating disorder (BED) is characterized by recurrent binge eating.

  • Binge eating = Eating a larger-than-normal amount of food in a discrete time period (2 hours). This is accompanied by feeling out of control during the eating episode, such as feeling like they cannot stop eating or control what or how much they are eating.

  • Unlike anorexia and bulimia nervosa, patients with BED do not try to control their weight through compensatory behaviors such as significantly restricting calories or purging. They are typically not as fixated on their weight and body shape.

Diagnostic Criteria 2

  • Recurrent episodes of binge eating.

  • Severe distress over binge eating.

  • Binge eating occurs ≥ once a week for at least 3 months.

  • NOT associated with compensatory behaviors (laxatives, vomiting, etc). Does not occur exclusively during the course of bulimia or anorexia.

  • Binge-eating episodes are associated with ≥3 of the following:

-Eating much more rapidly than normal.

-Eating until uncomfortably full.

-Eating large amounts of food when not feeling hungry.

-Eating alone due to feeling embarrased by how much one is eating.

-Feeling disgusted with oneself, depressed, or very guilty after binge-eating.

  • Severity is specified based on the frequency of binge-eating episodes per week. Mild = 1-3. Moderate = 4-7. Severe = 8-13. Extreme = ≥14. The level of severity may be increased to reflect other clinical symptoms or degree of functional disability.

Epidemiology/Pathogenesis 3, 4, 5, 6

  • Binge-eating disorder is the most common eating disorder among US adults. It is more prevalent than bulimia nervosa and anorexia nervosa combined.

  • 12-month and lifetime prevalence is ~1.6% and ~3.5% for women and ~0.8% and ~2.0% for men.

  • The gender ratio (~2:1) is less skewed in BED than bulimia or anorexia (~10:1).

  • Prevalence rates are comparable among racial and ethnic groups in most industrialized countries.

  • Most common age of onset is late adolescence or young adulthood but can occur at any age. BED occurs at a later median age (~21 years) than bulimia or anorexia (~16-18).

  • Can be chronic and relapsing illness, however remission rates are higher than for other eating disorders. A longitudinal study suggested only 18% of patients still had BED after 5 years.

  • As with most psychiatric disorders, the dominant theory suggests BED develops from a combination of genetic, biological, environmental, and psychosocial factors. BED runs in families, suggesting likely genetic influences. Neurobiological theories on possible causes of BED include: 1) reward center and and impulsivity dysregulation theory; 2) neurotransmitter dysregulation theory; 3) endogenous μ-opioid signaling dysfunction theory. There is also increased prevalence among individuals with depressive symptoms, weight dissatisfaction, and individuals seeking weight-loss treatment.

Clinical Pearls 7, 8, 9

  • History: Binge-eating disorder is distinct from obesity and can occur in normal weight, overweight, and obese individuals. Most obese individuals do not engage in recurrent binge-eating. Compared with weight-matched obese individuals, those with BED consume more calories, have greater functional impairment, more subjective distress, and greater psychiatric comorbidity. Having said all of that, BED is associated with higher rates of obesity and are at risk of developing metabolic syndrome, type 2 diabetes, high cholesterol, high blood pressure, heart problems, and digestive problems. One important note is that psychiatric comorbidity is linked to the severity of binge eating and not to the degree of obesity. Dieting, but not compensatory behaviors, follows the development of binge eating in many individuals with BED. Individuals are often ashamed of their eating problems and attempt to hide their symptoms and behaviors. Common triggers of binge eating include negative affect, interpersonal stress, negative feelings related to body weight/shape/food, boredom, and dietary restraint (cognitive effort or intention to restrain caloric intake).

  • Optional Questionnaires: Eating Disorder Examination (EDE; clinician-administered), Eating Disorder Examination Questionnaire (EDE-Q; self-report), SCOFF Questionnaire, Binge Eating Scale (BES), Binge Eating Disorder Screener-7 (BEDS-7).

  • Differential Diagnosis: The differential diagnosis includes medical conditions that lead to hyperphagia/binge eating (e.g. Kleine-Levin, Prader-Willi, or Kluver-Bucy). Rule out other eating disorders. Both bulimia and BED have recurrent binge eating, however individuals with BED do not engage in inappropriate compensatory behaviors and do not typically place undue influence of body weight/shape on self evaluation. Crossover from BED to other eating disorders is uncommon. Other psychiatric conditions in the differential diagnosis include mood disorders (increase appetite and weight gain = atypical feature specifier) or borderline personality disorder (binge eating = impulsive behavior criterion). If the full criteria for both disorders are met, both diagnoses can be given.

  • Comorbidities: Like bulimia nervosa, in binge-eating disorder, there is an association between mood disorders, impulsivity, personality disorders (most commonly borderline PD), anxiety disorders, and, to a lesser degree, substance use disorders.

Treatment 10, 11, 12, 13

  • Psychotherapy: Psychological interventions should be considered first-line treatment. One meta-analysis showed individual or group Cognitive Behavioral Therapy (CBT) to be most effective. Studies have generally found CBT to be more beneficial than pharmacotherapy. Evidence also supports the use of Dialectical Behavior Therapy (DBT), Interpersonal Therapy (IPT), focused Psychodynamic Therapy, structured self-help, mindfulness training, and psychoeducation. Therapy aims to help restore healthy eating behaviors, reduce binge frequency, change their relationship with food and their weight status, improve body image, develop new coping strategies, and help them better utilize their support systems.

  • Pharmacotherapy: Adults may be offered a trial of an SSRI as an additional first step. Fluoxetine (Prozac) is typically the first agent of choice. Fluoxetine is FDA approved for the treatment of bulimia nervosa (in adults) which has been shown to reduce frequency of binge eating, however it is technically an off-label use for BED. The effective dose is typically higher than average depression treatment (60-80 mg/day). Other SSRIs (e.g. sertraline, citalopram, escitalopram) have also demonstrated efficacy for reducing the frequency of binge eating. Consider lisdexamfetamine in patients who do not respond to one or two courses of an SSRI. Lisdexamfetamine (Vyvanse), a prodrug of dextroamfetamine, is currently the only drug to be FDA approved in the U.S. for the treatment of moderate to severe BED in adults. Its approval was based on the results of two 12 week studies, which showed a significantly greater reduction in binge eating days/week than placebo. There is some evidence to support topiramate. There is ongoing research on opioid antagonists (e.g. naltrexone) given the relationships between feeding and the endogenous opioid system. Other medications that have been used with some benefit include atomoxetine, armodafinil, bupropion, SNRIs, lamotrigine, zonisamide, acamprosate, and sodium oxybate.


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