Binge Eating Disorder (BED)

Eishita Manjrekar, PH.D.
Mark Zimmerman, M.D.

Basic Information

Definition

Binge eating disorder (BED) is characterized by recurrent binge eating episodes, during which an abnormally large amount of food is consumed in a short period of time, accompanied by a sense of loss of control. At least 3 of the following features need to be present in a binge eating episode:

1.

Consuming food faster than normal
2.

Consuming food until uncomfortably full
3.

Consuming large amounts of food when not hungry
4.

Consuming food alone due to embarrassment
5.

Feeling disgusted, depressed, or guilty after eating a large amount of food

In order to meet criteria for BED, individuals must engage in binge eating episodes at least once per week for 3 months, feel significant distress with regard to their binge eating behaviors, and not utilize compensatory behaviors (e.g., induced vomiting, laxative misuse, overexercising) seen in other eating disorders like bulimia nervosa.

Synonyms

Compulsive overeating
BED

ICD ICD-10-CM CODES
F50.81	Binge eating disorder
DSM-5: CODES
307.51

Epidemiology & Demographics

Incidence

To our knowledge, no incidence studies on BED yet exist.

Prevalence (In US)

Approximately 2% lifetime prevalence in adult community samples was found (women 3.5 %; men 2.0 %). BED was found to be the most common eating disorder in males—the female-to-male ratio being more balanced (about 3:2) compared with other eating disorders (about 9:1). Lower lifetime prevalence rates among 13- to 18-year-old adolescents (girls 2.3 %; boys 0.8 %) were found. The 12-month prevalence among adult women and men is 1.6 and 0.8%, respectively.

Predominant Age (In US)

Higher prevalence rates in females (1.75:1) were found among adults.

Genetics

•

BED appears to aggregate in families and have a significant genetic component
•

Family studies report odds ratios between 1.9 and 2.2 for the risk of BED in a relative of a proband with BED compared with relatives of controls
•

Twin studies of BED have reported heritability estimates ranging from 41% to 57% for varying definitions of this disorder

Risk Factors

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Mental health concerns and psychopathology (mood disorders, anxiety disorders, personality disorders, conduct problems, negative affectivity, substance abuse)
•

Temperament and coping style (e.g., high avoidance motivation, low distress tolerance, low extraversion and self-directedness)
•

Severe childhood obesity
•

Experience of bullying/weight-related stigmas
•

Lifestyle disruptions and deprivation
•

Family weight and eating concerns (family dieting, family history of bulimia nervosa, family overeating)
•

Quality of parenting (family discord, maternal/paternal problem parenting, parental separation/absence/death)
•

Sexual and physical abuse

Physical Findings & Clinical Presentation

•

Although not necessary for a diagnosis, individuals presenting with BED are often overweight or obese
•

BED is highly comorbid with other forms of psychopathology, especially mood and anxiety disorders. Individuals seeking treatment with acute symptoms of other disorders might not initially report binging episodes, which underscores the importance of thorough initial assessment
•

Males with BED are more likely to underreport symptoms
•

Disordered eating symptoms can improve or worsen over time, and diagnostic labels might transition from BED to other eating disorders over time
•

There is potential for higher suicide risk among individuals with BED, possibly because of comorbid psychopathology, and suicidal ideation/intent should be monitored
•

General difficulty to cope with negative emotions and avoidance of aversive experiences/feelings might be apparent
•

Significant shame and self-conscious emotions regarding bingeing behaviors might be present, often resulting in underreporting of binge-eating behaviors

Etiology

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Research suggests that individual factors (e.g., genetic, biologic, temperamental), environmental factors (e.g., family environment, external sources of stress), and their interactions each contribute.

Diagnosis

Differential Diagnosis

•

Important to establish the presence of objective binge eating episodes versus subjective binge eating episodes and non-binge forms of overeating.
•

Important to establish that binge eating episodes are not associated with the recurrent use of inappropriate compensatory behaviors (e.g., purging, overexercising).
•

Important to establish that binge eating episodes do not occur exclusively during the course of anorexia nervosa, bulimia nervosa, or avoidant/restrictive food intake disorder.

Workup

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Careful medical and psychosocial history
•

Physical examination reveals no specific diagnostic signs of BED
•

Mental status examination

Laboratory Tests

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No laboratory tests are diagnostic. However, given that BED is frequently associated with overweight and obesity, tests examining associated medical problems (e.g., Type II diabetes, high triglycerides) might benefit an individual’s overall treatment plan.

Imaging Studies

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Neuroimaging studies suggest there are corticostriatal circuitry alterations in BED similar to those observed in substance abuse, including altered function of prefrontal, insular, and orbitofrontal cortices and the striatum. Imaging is not recommended as part of routine evaluation.

Treatment

Nonpharmacologic Therapy

•

The primary goal of therapeutic approaches to BED is reduction and/or elimination of binge eating episodes and the associated symptoms of distress.
•

Variations of cognitive behavior therapy (CBT) and interpersonal psychotherapy (IPT) remain the most established treatments for BED.
•

Growing literature on other psychotherapeutic approaches to BED has also yielded empirical support for dialectical behavior therapy (DBT), and mindfulness-based therapies.
•

Combining different interventions at the same time does not add significant advantages. Planning sequential treatments, with more specific interventions for nonresponders, seems to be a more promising strategy.
•

Behavioral weight loss (BWL) and self-help interventions evidenced some efficacy in patients with lower psychopathological features. Moreover, BWL approaches have not fared as well as CBT and IPT approaches in ameliorating disordered eating patterns.
•

Morbidly obese patients with BED might be well-served by weight loss (bariatric) surgery, which has been found to be associated with sustained, substantial weight loss, as well as reduction in binge eating episodes.
•

Preliminary findings regarding electronically delivered psychotherapeutic interventions (e.g., Internet-based CBT) for BED have yielded some empirical support.
•

One of the limitations of extant literature is the predominant inclusion of female participants in RCTs.

Acute General Rx

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The pharmacotherapy literature on treating BED in the short-term has focused on achieving the following objectives: reducing the frequency of binge eating episodes, reducing weight, and improving associated psychopathology (e.g., depression/anxiety symptoms).
•

Preliminary support for specific medications within the classes of antidepressants, anticonvulsants, and antiobesity agents has been found for treating symptoms associated with BED.
•

Antidepressants are thought to influence treatment outcomes by addressing the mood and anxiety symptoms that often co-occur with BED. Anticonvulsants have been examined in the treatment of BED because of their success in treating other impulse control disorders. Antiobesity agents have been used to address the overweight and obesity that usually accompanies BED.
•

Lisdexamfetamine dimesylate (Vyvanse) is the only medication that has been approved by the Food and Drug Administration (FDA) for the treatment of BED. Two studies found that participants taking the medication experienced a decrease in the number of binge-eating days per week and had fewer obsessive-compulsive binge eating behaviors compared with those on placebo. Longer-term maintenance studies examining the treatment of BED have not yet been published.
•

Exploratory work using substance use treatment agents to address BED symptoms is currently under way.
•

The existing literature on pharmacotherapy approaches to BED has several limitations, including short duration of RCTs, and lack of adequately sized RCTs.

Chronic Rx

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The long-term treatment of BED using pharmacotherapy has not as yet been systematically investigated

Complementary & Alternative Medicine

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One study found that hour-long, weekly yoga sessions were associated with reductions in binge eating, BMI, and hip and waist measurements, and an increase in physical activity. More follow-up research is needed in this area.

Disposition

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Data on the long-term outcome of BED, including mortality, are scarce.
•

Most outcome data on BED are derived from RCTs. In studies on the outcome of binge eating disorder with a follow-up duration over 3 years, remission rates in the samples treated with psychotherapy ranged from 19% to 65% across the studies.
•

Prospective longitudinal studies with adolescents have found that girls with BED had a twofold risk of becoming overweight or obese, or developing high depressive symptoms compared with non-disordered girls. Among boys, weekly binges predicted drug use as well.
•

Various factors may affect treatment response to BED. For instance, higher frequency of binges, increased comorbid psychopathology, and decreased social/family support have been found to be associated with worse treatment outcomes.

Referral

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Referral to mental health specialists: For diagnosis and symptom management (using psychotherapy, pharmacotherapy)
•

Referral to nutrition, exercise specialist and/or bariatric surgeon: If patient with BED is morbidly obese, and has associated medical problems

Pearls & Considerations

Comments

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Individuals with BED who are overweight or obese and are interested in weight loss, should also be encouraged to engage in treatment for disordered eating. Although the psychological treatments for BED do not produce substantial weight loss, the elimination of binge eating protects against future weight gain.
•

If possible, including family in treatment can be helpful for building social and environmental supports, especially for adolescent and young adult clients.

Prevention

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There are no known ways to prevent BED (or other eating disorders). However, research suggests that involving education on weight stigma, healthy eating, and body confidence in interventions amongst school children might ameliorate future body dissatisfaction and disordered eating.

Patient/Family Education

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National Education Disorders Association (NEDA, https://www.nationaleatingdisorders.org/) provides patient, family, and professional information on eating disorders including BED.
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Binge Eating Disorder Association (BEDA, http://bedaonline.com/) provides patient, and professional information on BED.
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Additional, local and/or online support groups for BED are common and should be investigated.

Ferri – Binge Eating Disorder (BED)