Binge-Eating Disorder

Binge Eating Disorder (BED) is a feeding and eating disorder characterized by episodes of consuming food in a larger amount than is normal in a short time.

• In the United States, the 12-month prevalence is 1.6% for females and 0.8% for males.^[1]
  • It is common in adolescent and college-age samples.^[2]
  • This gender ratio is far less skewed than compared to bulimia nervosa.
• Binge-eating disorder is as prevalent among females from racial or ethnic minority groups as has been reported for white females.

• The development of binge-eating disorder is not well understood.^[3]
• Individuals typically report greater functional impairment, lower quality of life, and more subjective distress.
• Binge-eating disorder appears to have a persistent course, and is comparable to bulimia nervosa in terms of severity and duration.^[4]
• Dieting often follows the development of binge eating disorder (contrast this with bulimia nervosa, where dysfunctional dieting usually precedes the onset of binge eating).^[5]
• Individuals have an increased risk for weight gain and obesity.^[6]

• The most common psychiatric comorbidities are bipolar disorders, depressive disorders, anxiety disorders, and substance use disorders.^[7]
• Obesity, diabetes, hypertension, and chronic pain are common comorbid conditions.
• Binge-eating disorder occurs in both normal-weight/overweight and obese individuals. It is reliably associated with overweight and obesity in treatment-seeking individuals (but most obese individuals do not engage in recurrent binge eating).
• BED is more prevalent among individuals seeking weight-loss treatment.^[8]

• BED appears to run in families and may have a genetic component.^[9]

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. Eating, in a discrete period of time (e.g. - within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g. - a feeling that one cannot stop eating or control what or how much one is eating).

The binge-eating episodes are associated with at least 3 of the following:

1. Eating much more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of feeling embarrassed by how much one is eating
5. Feeling disgusted with oneself, depressed, or very guilty afterward

Marked distress regarding binge eating is present.

The binge eating occurs, on average, at least once a week for 3 months.

The binge eating is not associated with the recurrent use of inappropriate compensatory behaviour as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

• The context in which the binge eating occurs is based on clinician subjectivity on whether the intake is excessive (e.g. - it is during a celebration or holiday meal?).^[10]
• A single episode of binge eating need not be restricted to one setting. For example, an individual may begin a binge in a restaurant and then continue to eat after going home.^[11]
  • Continual snacking on small amounts of food throughout the day would not be considered an eating binge, however.^[12]
• Some individuals do not report a feeling of loss of control but instead say they have abandoned any efforts to control their eating. This can be considered as “loss of control” under the DSM-5 criteria.^[13]
• The most common triggers for binge eating episodes include negative affect (emotions), interpersonal stressors; dietary restraint; negative feelings related to body weight, body shape, and food; and boredom
• Importantly, binge eating must also be characterized by marked distress (Criterion C).^[14]
• Binge eaters are typically ashamed by their eating and thus, it usually occurs in secrecy or individuals will try to make it inconspicuous.^[15]

• Binge-eating disorder is thought to have similar neurobiological pathways as substance use disorders, and involves changes in reward processing and inhibitory control.
• Neuroimaging studies suggest that the medial orbitofrontal cortex and prefrontal cortex may be involved.

• Bulimia nervosa
  • Although both disorders involve recurrent binge eating, recurrent inappropriate compensatory behaviours (e.g. - laxative misuse, fasting, or self-induced vomiting) is absent in binge-eating disorder. Unlike bulimia nervosa, individuals with binge-eating disorder also typically do not show marked or sustained dietary restriction designed to influence body weight and shape between episodes. Rates of improvement are consistently higher in binge-eating disorder than bulimia nervosa as well.
• Obesity
  • BED is associated with being overweight and obesity but has several key features that are distinct from obesity. Psychiatric comorbidity and overvaluation of the body is higher in obese individuals with BED than in those without. In terms of prognosis, there are successful treatments for BED, but no effective long-term treatments for obesity.
• Anxiety disorders
  • Anxiety disorders are associated with binge eating; however, the individual only receives a diagnosis of binge eating disorder when binging episodes occur every week for 3 months.
• Kleine-Levin syndrome
  • In KLS, episodes of binges are also associated with excessive sleep.
• Depressive disorders and bipolar disorders
  • In mood disorders, episodes of binge eating occur during mood episodes only and are associated with other symptoms of a mood disorder. Increased eating in the context of a major depressive episode may or may not be associated with loss of control. If the full criteria for both a mood disorder and BED are met, both diagnoses can be given.
• Borderline personality disorder
  • Binge eating is part of the impulsive behaviour criterion that is part of the definition of borderline personality disorder. If the full criteria for both disorders are met, then both diagnoses should be given.^[16]

• Investigations related to over-eating such as a metabolic work up (e.g. - blood glucose, liver enzymes, cholesterol, triglycerides, HbA1c) may be indicated.

• Physical exam should be focused on medical issues related to obesity (e.g. - fatty liver disease, cardiac issues).

• Do not offer medication as the sole treatment for binge eating disorder.^[20][21]
• There is some evidence for lisdexamfetamine, sertraline,^[22] fluoxetine,^[23] and topiramate.^[24]
• Topiramate can be started topiramate at 25 mg/day and increased by 25 mg/day every 1 to 2 weeks, until reaching a dose of 150 to 200 mg/day. It could then be further increased up to a dose of 400 mg/day or more for selected patients in the absence of clinical response.^[25][26]