Year: 1996
Type: article
Abstract: Previous articles in this issue have described the characteristics and treatment of the classic eating disorders anorexia nervosa and bulimia nervosa. Binge-eating disorder, in contrast, is a newly recognized eating disorder characterized by episodic uncontrolled consumption of large amounts of food in the absence of the inappropriate compensatory methods that characterize bulimia nervosa, including vomiting, laxative abuse, fasting, or excessive exercise following an eating binge. The provisional criteria for binge eating disorder, which have been included in the Diagnostic and Statistical Manual of Mental Disorders (DSM)–IV, Appendix B: Criteria Sets and Axes Provided for Further Study 4 and are summarized here in Table 1 , specify that the individual must experience significant distress related to binge eating and must endorse several behavioral indicators of loss of control. Although the criteria do not specify that the affected individual must be overweight, most patients currently presenting for treatment for binge-eating disorder are overweight, and this article therefore focuses on overweight binge-eating disorder patients. The following patient is typical of a number of patients who have in recent years presented to our Eating Disorders Clinic requesting treatment: Ms. A. was a 39-year-old single advertising executive who lived alone in an affluent urban neighborhood. She presented to our clinic for treatment of binge eating since age 10. At the time of presentation, she weighed 194.5 lb at a height of 5 feet and 5.25 inches (body mass index [BMI] 32.1). She had a history of frequent dieting and estimated that she had been dieting for about three quarters of her adult life. Her most recent major diet took place over a 3-month period 2 years prior to presentation when she lost from 175 down to 140 lb on a liquid fast program, but within 6 months began to regain the weight. Her weight of 194.5 lb on presentation was her lifetime highest weight. Ms. A.'s eating binges occurred one to two times per day 3 to 4 days per week, usually while on the way home from work or late at night while home alone. A typical binge consisted of 1 to 1.5 pints of frozen yogurt, a piece of cake, and a candy bar consumed in about half an hour. Prior to binge eating, she often felt hopeless and felt that she had already eaten too much over the course of the day. She saw her eating binges as being reactive to various stresses in her life, including problems in relationships with men, conflicts at work, and chronically problematic relationships with her mother and various siblings. She was quite distressed about her binge eating, independent of its effect on her weight, and appeared well motivated for treatment. She had no history of vomiting, laxative or diuretic abuse, excessive exercise, or fasting. Ms. A.'s other psychiatric history was significant for past alcohol dependence, in remission for the past 5 years. She also had a past history of depression, but was not depressed at the time of presentation. Family history was negative for binge eating and obesity. Over the years, patients like Ms. A. have presented in various places. First, clinicians in weight-control clinics, beginning with Stunkard in 1959, 41 noted the presence of a subpopulation of binge eaters, and began to track the ways in which they differed from other obese patients who were not binge eaters. Second, eating disorder clinics, such as our own, received a number of calls from such individuals who usually did not qualify for treatment because they did not meet criteria for currently existing eating disorders. Finally, individuals, many of whom had binge-eating problems, banded together in self-help organizations, such as Overeaters Anonymous, to try to help one another with their binge-eating problems. In 1990, in the context of the development of the DSM-IV, several groups, including obesity researchers, eating-disorder researchers, and those experienced in nosology and epidemiology, joined together in a collaborative effort to develop criteria for this syndrome, which was given the name binge-eating disorder. This group also performed studies to test the reliability and validity of the new syndrome and to determine its prevalence and associated features. The diagnostic criteria were developed somewhat arbitrarily by: (1) borrowing the concept of binge eating from the criteria for bulimia nervosa; (2) interviewing a number of volunteer from self-help organizations and from local weight-control programs, developing lists of features that characterized them, and testing these features in further interviews; and (3) polling experts in the treatment of obesity and eating disorders. The resulting set of diagnostic criteria should be regarded as provisional rather than definitive. Others 15 have argued that the specification of diagnostic criteria ought to await the completion of epidemiologic studies designed to derive empirically the criteria that most meaningfully separate binge-eating disorder from the larger universe of eating disorders not otherwise specified. Such studies are currently in progress. The DSM-IV criteria have been used in a number of studies concerning the characteristics and treatment of binge-eating disorder. Spitzer and colleagues 38 , 40 carried out two multicenter studies using the provisional criterion set, operationalized in a self-report format, which was administered in a variety of weight-loss clinics and community samples. In the first study, 38 about 30% of subjects in weight-loss clinics and 2% in community samples met criteria for binge-eating disorder, with higher percentages engaging in regular binge eating but not meeting full criteria for the disorder. The results from the second field trial were similar. 40 These and other studies have begun to characterize patients with binge-eating disorder compared with their equally obese nonbinge eating counterparts. Patients with binge-eating disorder, like normal-weight patients with bulimia nervosa, are markedly distressed concerning body image and frequently diet. 38 , 40 , 49 The temporal link between dieting and the emergence of binge eating, however, which is characteristic of normal-weight patients with bulimia nervosa, does not seem to occur in most patients with binge-eating disorder. 49 , 53 The multicenter field trials also attempted to identify features associated with a diagnosis of binge-eating disorder that would lend support to its recognition as a meaningful diagnostic category. They found that patients with binge-eating disorder, compared with obese patients without binge-eating disorder, showed greater impairment in work and social functioning, increased general psychopathology, and more frequent history of depression, substance abuse, and treatment for emotional problems. 38 , 40 One of the most consistent findings across a number of centers 32 , 40 , 52 has been that patients with binge-eating disorder have an increased frequency of psychiatric symptoms and diagnoses compared with equally obese nonbinge eaters. One notable study 52 found that the prevalence of Structured Clinical Interview for DSM-III-R diagnosed axis I and axis II disorders in a nonclinical sample was greater in obese binge eaters than in obese nonbinge eaters, with the greatest difference being in major depression, which occurred in more than half of the binge-eating sample. One possible explanation was that, given the known correlation between degree of obesity and prevalence of binge eating, 43 the observed difference was actually due to increased psychopathology in the heaviest individuals. When the investigators divided the group into moderately and morbidly obese, however, there were no differences in psychopathology. Therefore, the elevated risk for psychopathology seemed to be related to binge eating rather than degree of obesity. The causality of the relationship between obesity and various psychiatric diagnoses could not be inferred from this study and is an important topic for future research. Finally, given that the cardinal feature of binge-eating disorder is a disturbance of eating behavior, the direct examination of the eating patterns of these patients is clearly relevant. In other words, do patients with binge-eating disorder actually eat differently from equally weighted nonbinge eaters, or do they simply perceive their eating differently? Two studies have examined this question. Our group 18 studied the eating behavior of 10 women with binge-eating disorder and 10 equally obese women without binge-eating disorder (mean BMI about 32). Subjects were asked come to the laboratory for two meals in which they were instructed to “let yourself go and eat as much as you can.” In a multi-item meal (an array of foods including bread, rice, green beans, lettuce, tomato, fish or chicken, yogurt shake, cookies, cake, potato chips, and ice cream) subjects with binge-eating disorder ate significantly more than subjects without binge-eating disorder (1515 kcal versus 1115 kcal). In contrast, in a single-item meal (ice cream), subjects ate comparable amounts. Yanovski and colleagues 51 performed a similar study with two important differences: mean BMI was about 39.5, and subjects were given a multi-item binge meal and a multi-item nonbinge meal, in which they were asked to “eat as much as you would in a normal meal.” In both the binge and nonbinge conditions, subjects with binge-eating disorder ate more than those without binge-eating disorder (2963 versus 2017 kcal in binge condition, 2343 versus 1640 kcal in nonbinge condition). When compared with our study, patients (binge-eating disorder and non–binge-eating disorder) ate more under all conditions than our patients, possibly related to the fact that they were substantially more overweight. Taken together, these studies suggest that: (1) under certain conditions, obese individuals with binge-eating disorder eat differently than those without binge-eating disorder; (2) bingers eat differently from nonbingers even when they are not binge eating; (3) in addition to presence or absence of binge-eating disorder, degree of obesity may be an important contributor to the amount consumed in a laboratory setting.
Author: Michael J. Devlin
Institution: New York State Psychiatric Institute
Language: English
Subfield: Clinical Psychology
Field: Psychology
Domain: Social Sciences
Open Access status: hybrid
Estimated APC paid: $2,900
OpenAlex ID: W2157405715