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Binge Eating Disorder
Introduction
Binge eating disorder is a psychological condition characterized by episodes of uncontrolled consumption of large amounts of food in a short period, typically <2 hours. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), binge eating disorder involves consuming more food compared to what is typical in similar circumstances at least once a week for 3 months without engaging in compensatory behaviors such as purging or excessive exercise. The disorder is also associated with at least 3 of the following behaviors:
- Eating much more rapidly compared to normal
- Eating until feeling uncomfortably full
- Eating large amounts of food when not feeling physically hungry
- Eating alone due to feeling embarrassed about the quantity consumed
- Feeling disgusted with oneself, depressed, or very guilty afterward [1]
Binge eating disorder is also characterized by the distress the binge eating behavior causes the patients. The severity of BED is categorized based on the frequency of weekly binge eating episodes:
- Mild: 1 to 3 episodes
- Moderate: 4 to 7 episodes
- Severe: 8 to 13 episodes
- Extreme: ≥14 episodes
- In partial remission:<1 episode on average for a sustained period
- In complete remission: 0 episodes for a sustained period
Etiology
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Etiology
Binge eating disorder arises from multiple biological, psychological, social, and cultural factors. Therefore, a sole defined cause has not been identified. The condition has a heritability estimate of 41% to 57%.[2]
Risk Factors for Binge Eating Disorder
Biological risk factors include the following:
- Substance abuse
- DRD2 polymorphisms, mediating reward sensitivity
- OPRM1 polymorphisms, mediating reward sensitivity
- 5-HTT polymorphisms (mixed evidence)
- MC4R polymorphisms (mixed evidence)
- Alterations in gut microbiome [3][4]
- Alterations in cortical connectivity [5]
The following psychological risk factors are also associated with binge eating disorder:
- Premorbid negative affectivity
- Perfectionism
Social and developmental risk factors include the following:
- Conduct problems
- Childhood obesity
- Family weight concerns and eating problems
- Parenting problems and family conflict
- Parental psychopathology
- Physical or sexual abuse
- Childhood loss of control eating, which may be considered a prodrome in adults as well
Epidemiology
Binge eating disorder is more common in women compared to men, often starting in late adolescence or early adulthood. This condition is also more common in students and those without a college education. The lifetime prevalence of binge eating disorder averages 1.9% in international surveys and 2.6% in studies conducted in the United States. Approximately 79% of people with a history of binge eating disorder have at least 1 lifetime psychiatric comorbidity. In an estimated 48.9% of people, ≥3 comorbid conditions are observed, including:
- Anxiety disorder in 56.1%, with phobia being the most common
- Mood disorder in 46.1%, with major depressive disorder being the most common
- Disruptive behavior disorder in 25.4%, with intermittent explosive disorder and attention-deficit/hyperactivity disorder being the most common
- Substance use disorder in 23.7%, with alcohol use disorder being the most common [6]
Compared to individuals without eating disorders, those with binge eating disorders are statistically less likely to have a body mass index (BMI) <25 and are more likely to have a BMI ≥25. However, the precise distribution of these differences varies for each population tested.
Pathophysiology
Research has emphasized the roles of negative affect regulation, alterations in reward processing, and inhibitory control in binge eating disorder.[7] The affect regulation model suggests that binge eating episodes precede and relieve negative affect, although the latter point has been questioned.[8][9] A food addiction hypothesis has been proposed due to similarities between binge eating disorder and substance use disorders in terms of reward processing and inhibitory control. This hypothesis suffers from a lack of evidence of tolerance and withdrawal.[10]
Patients with binge eating disorder demonstrate decreased resting state functional connectivity in the striatum [11] and decreased descending response inhibition from the prefrontal cortex.[12] The inferior frontal gyrus and insula are also dysfunctional in binge eating disorder and typically work in concert with the prefrontal cortex to exert descending control of behavior.[13] Evidence for greater activation of the dorsal anterior cingulate cortex in response to cues related to high-energy-density foods indicates altered reward processing and salience of food.[14] Compared to patients with bulimia nervosa, differences in default mode network connectivity may mediate binge eating disorder's lack of compensatory behavior.[15]
History and Physical
Clinical Assessment
Because binge eating disorder is characterized by episodes of uncontrolled consumption of large amounts of food to various degrees of severity, clinicians must inquire about clinical factors associated with eating disorders. Furthermore, clinicians should evaluate clinical features specific to binge eating disorder. If binge eating disorder is suspected, the clinician should assess the following clinical features to assist with diagnosis:
- Frequency of binge eating episodes
- Triggers for binge eating episodes
- Duration of episodes
- Amount of food consumed during episodes and level of hunger related to an episode
- Feelings associated with the binge, such as loss of control and negative emotions before or after
- Speed of eating
- Age of onset of binge eating behavior
- Compensatory behaviors, such as purging, exercise, and restriction
- Comorbidities, such as psychiatric and somatic
- Substance abuse
- Family history of psychiatric and somatic [1]
In addition, the patient's nutritional status should be assessed, including:
- Dieting and lifetime weight history
- Physical activity and exercise
- Current eating pattern and dietary choices
- Types of overeating, such as overeating at meals, night eating, snacking, and grazing
Physical examination should include monitoring body weight and identifying potential obesity complications, such as metabolic syndrome, through waist circumference, body mass index, blood pressure, and other clinical indicators.
Evaluation
Psychiatric Screening for Binge Eating Disorder
Several screening questionnaires are used to assess for various eating disorders. Questionnaires used to evaluate binge eating disorders include:
- Binge eating scale [16]
- Three-factor eating questionnaire [17]
- Body shape questionnaire [18]
- Eating disorders examination [19]
- Structured clinical interview for the diagnosis of DSM disorders
- Questionnaire of eating and weight patterns [20]
Additional Evaluation
In patients with suspected binge eating disorder, further evaluation for potential comorbid conditions should also be performed. Medical status evaluation should notably include the following comorbidities associated with obesity and excess body weight:
- Hypertension
- Hyperlipidemia
- Diabetes mellitus
- Gastroesophageal reflux disease
- Hepatobiliary disease
- Coronary artery disease
- Obstructive sleep apnea
- Hypothyroidism
Treatment / Management
Most individuals with eating disorders, including binge eating disorder, do not receive adequate care as the condition is often missed, and patients do not have sufficient access to appropriate resources. Therefore, clinicians should strive to implement evidence-based treatments into routine clinical care and expand access to underserved populations. Goals for patients seeking treatment for binge eating disorder include a reduction in episodes, a reduction in comorbidities, and a reduction in body weight.[21] The American Psychiatric Association (APA) practice guideline for eating disorders recommends initiating treatment with either individual or group psychotherapy using cognitive behavioral therapy or interpersonal psychotherapy. If the patient does not respond to psychotherapy or strongly prefers medication, pharmacotherapy options include lisdexamfetamine, selective serotonin reuptake inhibitors, and other medications. Behavioral weight loss strategies may also be beneficial for managing weight and reducing binge episodes. Transcranial magnetic stimulation and transcranial direct current stimulation are being investigated for use in binge eating disorder.[22](A1)
Psychotherapy
Effective psychotherapy treatments for binge eating disorder include cognitive behavioral therapy, interpersonal psychotherapy, and dialectical behavioral therapy.
Cognitive Behavioral Therapy
Cognitive behavioral therapy focuses on identifying and changing maladaptive patterns of thought and behavior. Multiple randomized controlled trials have studied cognitive behavioral therapy for binge eating disorder. Patients can be treated through a clinician or a self-help program,[23][24][23] both being equally effective. Cognitive behavioral therapy self-help programs are comparable to behavioral weight loss methods, such as calorie restriction and increased activity, in short-term outcomes and are more effective in specialty settings. Cognitive behavioral therapy has a high rate of abstinence, is well tolerated, and maintains remission for 1 to 2 years. The speed of response to treatment is a good prognostic sign. Self-help programs focus on:(A1)
- Creating regular eating patterns
- Monitoring eating habits
- Learning self-control techniques
- Learning problem-solving techniques
Interpersonal Psychotherapy
Interpersonal psychotherapy focuses on interpersonal stressors, functions, and roles. This psychotherapy modality can take place in a group format or individual format. The improvements in interpersonal function are believed to reduce negative affect and binge eating episodes, focusing on low self-esteem and perfectionism.[25] Interpersonal psychotherapy techniques include:(A1)
- Identifying the interpersonal area that links to binge eating episodes.
- Experimentation or constructive changes in problematic interpersonal relations.
Dialectical Behavioral therapy
Dialectical behavioral therapy focuses on developing tools for affect regulation.[26] This therapy helps patients balance dichotomies in feeling, behavior, and thinking. Patients undergoing dialectical behavioral therapy learn various skills, including:(A1)
- Mindfulness
- Distress tolerance
- Emotional regulation
- Interpersonal effectiveness, which is sometimes neglected in studies to avoid overlap with interpersonal psychotherapy
Pharmacotherapy
Pharmacotherapy should be used as first-line therapy in patients who do not have access to psychotherapy, decline psychotherapy, or prefer medications. The APA recommends starting with selective serotonin reuptake inhibitors or lisdexamfetamine. Medication options include:
- Lisdexamfetamine (the only medication with Food and Drug Administration approval for moderate-to-severe binge eating disorder in adults)[27]
- Selective serotonin reuptake inhibitors, such as sertraline, fluoxetine, fluvoxamine, escitalopram, and citalopram [28]
- Topiramate [29]
- Zonisamide [30]
- Armodafinil [31]
- Methylphenidate [32]
- Atomoxetine [33] (A1)
Behavioral Weight Loss
Behavioral weight loss is an evidence-based strategy that helps with weight loss and reduces binge eating episodes by decreasing caloric intake, increasing activity, and focusing on the nutritional quality of food. If the patient has developed significant physical comorbidities, referring them to a weight loss clinic or bariatric surgeon may be advisable.
Differential Diagnosis
The following conditions should be considered when evaluating binge eating disorder:
- Obesity: Patients with binge eating disorder are more likely to be obese, but it should not be assumed that every obese patient engages in binge eating. Obese patients with binge eating disorder are more likely to overvalue body weight, have psychiatric comorbidities, and respond to psychotherapy interventions for their weight management.
- Bulimia nervosa: Binge eating disorder is different from bulimia nervosa because there is no compensatory behavior following excessive eating. Patients with binge eating disorder are less likely to show long-term dietary restrictions to manage their weight compared to those with bulimia nervosa.
- Anorexia nervosa, binge eating or purging type: The distinction between this subtype and binge eating disorder is the lack of compensatory behavior negating excessive eating.
- Borderline personality disorder: Part of the diagnostic criteria for this condition is impulsive behavior, which is self-damaging, with binge eating being a typical example. The binge eating disorder should only be diagnosed if the criteria are met.
- Night eating syndrome: This condition is limited to excessive eating either after the last meal of the day or after waking at night.
- Mood disorders: An increase in appetite is an element of the diagnostic criteria. In addition, some patients with mood disorders overeat to diminish their distress. The binge eating disorder should only be diagnosed if the criteria are met.
- Anxiety disorders: Some patients with anxiety disorders overeat to diminish their distress, but the binge eating disorder should only be diagnosed if the criteria are met.
- Kleine-Levin syndrome: A rare parasomnia that includes binge eating, hypersomnia, hypersexuality, and cognitive or behavioral disturbances.
Prognosis
Longitudinal studies suggest a chronic relapsing and remitting course that is less likely to evolve into another eating disorder compared to bulimia nervosa or anorexia nervosa.[2] Binge eating behavior in children and adolescents is associated with an increased risk of depression, substance use, and excess weight gain.[34] In addition, binge eating behavior worsens the risk of complications from obesity, independent of the degree of obesity.[35]
Complications
Most patients with binge eating disorder are overweight or obese;[36] associated complications of binge eating disorder are related to this include:
Deterrence and Patient Education
Patients should be counseled regarding the disorder and how to cope with binges. Awareness of binge episodes and knowledge of strategies for self-control help prevent the cycle of binging and guilt. Over-evaluating body shape and weight produces dysfunctional eating and dieting behavior, which in turn causes physiological and psychological vulnerability to episodes of binge eating.[40] The following interventions should be included in patient education:
- Monitor eating patterns
- Track meals and snacks
- Limit weight tracking to avoid becoming preoccupied with the number
- Identify and track triggers, such as changes in eating behavior, substance use, and mood or anxiety symptoms
- Avoid people, places, and things that trigger binges
Enhancing Healthcare Team Outcomes
Patients with binge eating disorders should be treated by an interprofessional team, including psychiatrists, endocrinologists, psychologists, pharmacists, nutritionists, social workers, educational professionals, and nurses. Counseling from nutritionists plays an essential role in organizing and planning meals and behavioral weight loss therapy for these patients.[41] As binge eating disorder is associated with comorbid psychological conditions, the involvement of psychologists and social workers is indicated. Clinicians should be well-trained in evaluating and treating patients with this disorder. Bariatric and psychiatric nurses are involved with patient and family education, monitoring of patients, and documentation for the team. Pharmacists evaluate prescribed medications for appropriateness, dosage, and drug interactions and report any concerns to the rest of the team.
Clinicians should be aware that patients with binge eating disorders are vulnerable to shame and stigma and find it distressing to share their symptoms and concerns with healthcare professionals.[42] The management and education should be tailored to the age and level of development. Healthcare professionals should also assess for signs of bullying, teasing, abuse, and neglect. Team members should address any misconception regarding binge eating disorders that the patients or their families might have. The clinician should communicate with the patient nonjudgmentally, and the patient's weight and appearance should be addressed with care. Clinicians should foster a working relationship with those who care for patients with binge-eating disorders.[43] The clinician and all interprofessional team members should show empathy, respect, and compassion and provide suitable information for binge eating disorders and obesity. Family members, guardians, teachers, and peers should also be encouraged to support the patient during treatment. In addition, family members should undergo an assessment for eating disorders. The treatment team should offer emergency plans if the patient is at a high risk of a psychiatric event.
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