Practice Essentials
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) characterizes Binge Eating Disorder (BED) as consisting of the following: [1]
1. Eating, in a discrete period of time within any 2-hour period, an amount of food that is definitely larger than what most people would eat in a similar period under similar circumstances
2. A sense of lack of control over eating during the episode, a feeling that one cannot stop eating or control what or how much is eaten, and marked distress associated with the binge-eating episodes; the episodes occur on average at least once a week for at least 3 months, are not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa, and do not occur exclusively during the course of bulimia nervosa or anorexia nervosa; three or more of the following factors are also present:
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Eating much more rapidly than normal
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Eating until feeling uncomfortably full
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Eating large amounts of food when not feeling physically hungry
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Eating alone because of feeling embarrassed by how much is being eaten
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Feeling disgusted with oneself, depressed, or very guilty afterward
BED was added as a distinct disorder in the DSM-5 after extensive research supported its clinical utility and validity, as it had been in the appendix of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM–IV-TR) as a proposed disorder. The significant difference from the preliminary DSM-IV criteria required for diagnosis included a minimum average frequency from at least twice weekly for 6 months to at least once weekly over the preceding 3 months. [2]
Individuals with BED are typically ashamed of their eating problems and attempt to conceal their symptoms, so they may binge eat in secret. Binge eating can be associated with an acute feeling of loss of control and marked distress. It can be triggered by interpersonal stressors, negative feelings related to body image, and boredom. After repeated binge-eating episodes occur, they are often preceded by negative affect. Over time, the episodes of binge eating can generalize to a regular pattern of uncontrolled overeating. [3]
Background
Binge eating disorder (BED) was first characterized in 1959 by Stunkard as the presence of recurrent episodes of binge eating. BED can also include night eating with resultant weight gain but by definition does not include the use of vomiting or medications such as laxatives, emetics, or diuretics. [4]
Rumination and anxiety typically includes the recurrent thought: "Will I get fat?" [5]
Neural network areas involved show impairments in reward processing, inhibitory control, and emotion regulation, which can respond to psychotherapeutic interventions. [6]
Anatomy
Neuroanatomical studies of neuropeptide Y, a compound in the brain, have shown that it may regulate and control weight. Areas in the brain involved in binge eating include the medial orbitofrontal cortex, insula, and striatum; altered brain circuitry may also be associated with taste pleasantness and reward value. When 6-hydroxydopamine was injected into noradrenergic terminals, a direct cause was loss of normal function of hypothalamic ventral bundle termination areas with resultant hyperphagia, thus confirming that a function of the noradrenergic bundle included suppression of feeding, a function critical to body weight regulation. Without an intact noradrenergic bundle, d-amphetamine–induced loss of appetite was not observed. [7]
The anterior insula integrates sensory reward aspects of taste in the service of nutritional homeostasis as corticolimbic circuits regulate appetite. [8]
Pathophysiology
Alterations in the left orbitofrontal cortex, as can occur with lesions, result in increased insula volume, a finding that is nonspecific and seen in all eating disorders. Increased gray matter gyrus rectus volume specifically correlates with increased weight gain and an exaggerated response to sucrose pleasantness ratings in general. [8] Reduced white matter in the medial temporal lobe, as well as in the parietal lobe, may also be associated with binge eating disorder (BED). [9]
Overvaluation of body weight and a specific focus that one is overweight can begin in childhood; this may account for the internalization of weight bias and may be a belief that is modeled between caregivers and children and that continues into adolescence and young adulthood.
In a study, 245 treatment-seeking obese individuals with BED were evaluated with diagnostic and semistructured interviews and completed the Weight Bias Internalization Scale (WBIS) and the Rosenberg Self-Esteem Scale (RSE). Correlations and bootstrapping mediation analyses were computed to evaluate the relationships among self-esteem, overvaluation of shape/weight, and weight bias internalization. Significant correlations emerged between WBI, RSE, and overvaluation of shape and weight. Body mass index (BMI) did not correlate with any measure, and binge-eating frequency correlated only with overvaluation. Mediation analyses provided support for the hypothesis that overvaluation of shape and weight mediates the relationship between self-esteem and weight bias internalization.
Binging may acutely relieve negative mood; however, afterward, it generally causes the person’s negative mood to return even more intensely, reinforcing binging via negative reinforcement. Lower self-esteem and overvaluation of shape and weight contribute to weight bias internalization among patients with BED. [10]
Etiology
A longitudinal study in Australia that monitored 1,383 persons from pregnancy to age 20 years elucidated early childhood factors of female sex and parent-perceived child overweight at age 10 years as being significant multivariate predictors. Later on, eating, weight, and shape concerns of the adolescent at age 14 years were predictive of later-onset binge-eating disorder. Evaluation of family interaction, including observing the binge eater engaging in a meal with his or her family, may reveal pathological family dynamics. [9]
A study by Bauer et al utilized eye tracking technology and found that persons with an eating disorder tend to look more at unattractive areas of their body; this may explain the cognitive distortion involved and the preoccupation and distress over one's body size. [11]
Epidemiology
One US study found that the overall lifetime incidence of binge eating disorder (BED) could be as high as 3.5% among adult (>18 years) women and 2% among men, with slightly lower rates among younger persons aged 13–18 years (girls, 2.3%; boys, 0.8%). [10]
In a study of a large cohort of adolescents and young adults (in the Growing Up Today Study of the children of the Nurses’ Health Study II, a cohort study of >116,000 female registered nurses in the Boston, Massachusetts, area), binge eating was more common among females and was associated with incident overweight/obesity and with the onset of high depressive symptoms, as well as with initiation of marijuana use and other drugs, but not binge drinking. The prevalence of overeating or binge eating increased with age and peaked at 3.2% at age 19 years and was more common among females than males, with 2.3%-3.1% of females and 0.3%-1% of males reporting binge eating between ages 16 and 24 years. [12]
Studies have reported significantly elevated relative risk among family members of persons with BED, and data from twin studies indicated a range of heritability estimates ranging from 41%–57%. [13, 14]
Cultural factors may play a role in incidence, as well as access to care for binge eating. Asian Americans are more likely than whites to report binge eating; however, Asian Americans are less likely to receive services for binge eating. [15]
Gay and bisexual men with an eating disorder had a significantly higher prevalence of anxiety and substance-abuse disorders than gay and bisexual men without an eating disorder, similar to results from studies of predominantly heterosexual men with eating disorders in the general population, who were more likely to have anxiety and substance-abuse disorders than men without eating disorders. Lesbians and bisexual women with eating disorders were more likely to have a mood disorder than lesbians and bisexual women who did not have an eating disorder. [16]
Among 1680 individuals (32 blacks, 1648 whites) who received treatment for an eating disorder at a specialized center between 1979 and 1995 and who had completed an eating disorder questionnaire, blacks were more likely to report dissatisfaction with their body; they were also more likely to be obese than the white participants. This study was relatively small in number, as the 32 black participants were matched to 153 white participants; thus, the findings of this study should be interpreted with caution, as they should be replicated with a larger sample size. [17]
Another study examined interventions in African American women and found that technology can be helpful for self-monitoring. [18]
An Australian study by Mulders-Jones, Mitchison, Girosi and Hay in 2017, found no stratification by socioeconomic status for eating disorders, thus highlighting the imporance of considering the possibility of an eating disorder for all persons, including those unemployed or underemployed. [19]
Prognosis
Children, adolescents, and adults may experience a prodromal phase prior to meeting full criteria for binge-eating disorder. [20] Persons with binge eating disorder (BED) may be older than individuals with bulimia or anorexia nervosa who seek treatment. Long-term outcome studies indicate that BED may have a more favorable remission rate than other eating disorders. The severity, persistence, and duration, as well as suicide risk, for BED are comparable. [21]
Patient Education
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