Binge-eating
Disorder
As noted
earlier, binge-eating disorder is a proposed diagnos-tic category related to,
but quite distinct from, bulimia nervosa. Individuals with binge-eating
disorder, like individuals with bulimia nervosa, repeatedly engage in episodes
of binge-eating but, unlike patients with bulimia nervosa, do not regularly
utilize inappropriate compensatory behaviors. Binge-eating disorder has been
the focus of sustained attention only in the last decade. The clinical utility
of the information which quickly developed following the recognition of bulimia
in the DSM nomenclature was an important source of interest in binge-eating
disorder.
Suggested
diagnostic criteria for binge-eating disorder are in-cluded in an appendix of
DSM-IV-TR which provides criteria sets for further study. These criteria
require recurrent episodes of binge-eating, which are defined just as for
bulimia nervosa. The major difference from bulimia nervosa is that individuals
with binge-eating disorder do not regularly use inappropriate compensatory
behavior, although the precise meaning of “regu-larly” is not specified. Other
differences from the definition of bulimia nervosa relate to the frequency of
binge-eating: individu-als with bulimia nervosa must binge-eat, on average, at
least two times per week over the last 3 months, whereas individuals with
binge-eating disorder must binge-eat at least 2 days per week over the last 6
months. A major reason for the difference in the criteria is that the end of a
binge episode in bulimia nervosa is usually clearly marked by the occurrence of
inappropriate compensatory behavior, like purging, whereas in binge-eating
disorder, the end of a binge episode may be more difficult to identify
precisely. The criteria attempt to deal with this definitional difficulty by
requir-ing the frequency of binge-eating to be measured in terms of the number
of days per week on which episodes occur and, because of the potential
difficulty in distinguishing “normal” overeating from binge-eating, to require
a 6 month duration, rather than 3 months for bulimia nervosa. In addition, the
suggested DSM-IV-TR cri-teria for binge-eating disorder require that
individuals report be-havioral evidence of a sense of loss of control over
eating, such as eating large amounts of food when not physically hungry.
Finally, while there is some evidence that individuals with binge-eating
disorder tend to be more concerned about body image than in-dividuals of
similar weight, the criteria for binge-eating disorder require only that there
is marked distress over the binge-eating. Thus, the criteria for binge-eating
disorder do not require that self-evaluation be overly influenced by concerns
regarding body weight and shape, as is required for bulimia nervosa.
The
epidemiology of binge-eating disorder is uncertain. Cross-sectional studies
suggest that the prevalence of binge-eating dis-order among adults is a few
percent and that the prevalence is higher among obese individuals in the
community and among obese individuals who attend weight loss clinics.
Similarly, the frequency of binge-eating disorder increases with the degree of
obesity. In contrast to anorexia nervosa and bulimia nervosa, in-dividuals with
binge-eating disorder are more likely to be men (the female to male ratio is
roughly 1.5 : 1 compared with approx-imately 10 : 1 for anorexia nervosa and
bulimia nervosa), from minority ethnic groups and middle-aged
Very
little is known about the etiology of binge-eating disorder. Binge-eating
disorder is clearly associated with obesity, but it is uncertain to what degree
the binge-eating is a contributor to and to what degree a consequence of, the
obesity.
In
theory, binge-eating disorder should be easy to recognize on the basis of patient
self-report: the individual describes the frequent consumption of large amounts
of food in a discrete pe-riod of time about which he or she feels distressed
and unable to control. Difficulties arise, however, because of uncertainty
about what precisely constitutes a “large amount of food”, especially for an
obese individual and regarding what constitutes a discrete period of time. Many
individuals describe eating continuously during the day or evening, thereby
consuming a large amount of food, but it is not clear whether such behavior is
best viewed as binge-eating. Individuals who meet the proposed definition of
binge-eating disorder clearly have increased complaints ofdepression and
anxiety compared with individuals of similar weight without binge-eating
disorder.
The
assessment of individuals who may have binge-eating disor-der parallels that of
individuals who may have bulimia nervosa. It is important to obtain a clear
understanding of daily food intake and of what the individual considers a
binge. As in the assess-ment of bulimia nervosa, the interviewer should inquire
about the use of purging and other inappropriate weight control methods.
Individuals who describe binge-eating disorder are likely to be obese, and it
is important to obtain a history of changes in weight and of efforts to lose
weight. The interviewer should also inquire about symptoms of mood disturbance
and anxiety.
The
salient general medical issue is that of obesity. Individuals with binge-eating
disorder who are obese should be followed by a primary care physician for
assessment and treatment of the complications of obesity. There is no evidence
suggesting that the behavioral disturbances characteristic of binge-eating disor-der
add to the physical risks of obesity. Whether the presence of binge-eating
disorder affects the natural history of obesity is an intriguing but unanswered
question.
As noted
above, the most difficult issue in the diagnostic assess-ment of binge-eating
disorder is determining whether the eating pattern of concern to the individual
meets the proposed definition of binge-eating. There are numerous varieties of
unhealthy eat-ing, such as the consumption of high fat foods and the nosology
of these patterns of eating is poorly worked out.
Some
individuals with atypical depression binge-eat when depressed; if the
individual meets criteria for both binge-eating disorder and an atypical
depression, both diagnoses should be made.
As the
recognition of binge-eating disorder is quite recent, there is little
definitive information about the natural history of this disorder. However,
both controlled treatment studies and follow-up studies of community samples
indicate that there is substantial fluctuation over time in the frequency and
severity of the cardinal symptoms of this disorder.
For most
individuals with binge-eating disorder, there are three related goals. One is
behavioral, to cease binge eating. A second focuses on improving symptoms of
mood and anxiety disturbance which frequently are associated with binge-eating
disorder. The third is weight loss for individuals who are also obese.
Treatment
approaches to binge-eating disorder are currently un-der active study. There is
good evidence that psychological (e.g CBT) and pharmacological (e.g., SSRI)
interventions which are effective for bulimia nervosa are also useful in
reducing the binge frequency of individuals with binge-eating disorder and in
alleviating mood disturbance. However, it is not clear how helpful these
approaches are in facilitating weight loss. Stand-ard behavioral weight loss
interventions employing caloric restriction appear useful in helping patients
to control binge-eating, but the benefits of such treatment have not been
com-pared with those of more psychologically-oriented treatments, such as CBT.
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