Eating Disorders

10.3 Binge Eating Disorder and “Other” Eating Disorders

Binge eating disorder An eating disorder characterized by binge eating without subsequent purging.

Like most other people, you’ve probably had occasions when you’ve eaten too much—when you felt stuffed and uncomfortable. You may even have felt as if you “binged.” Odds are, though, that you don’t have binge eating disorder, which is characterized by a pattern of binge eating without subsequent purging (American Psychiatric Association, 2013). Or perhaps you—or people you know—have a pattern of eating that is disordered but doesn’t quite meet the criteria for anorexia, bulimia, or binge eating disorder. In what follows, we discuss binge eating disorder and disordered eating.

What Is Binge Eating Disorder?

As noted in TABLE 10.5, binge eating disorder is marked by a specific pattern of out-of-control binge eating in which the person must have at least three of the following symptoms: eat faster than normal, eat until uncomfortably full, eat a lot even when not hungry, eat alone because of being embarrassed by the quantity eaten, or have significant negative feelings about himself or herself about the amount eaten. People with this disorder do not typically fantasize about food or enjoy eating (either when bingeing or when not bingeing), and the bingeing causes distress. Note that binge eating disorder involves out-of-control binge eating and not weight per se; being overweight is not a psychological disorder.

Table : TABLE 10.5 • DSM-5 Diagnostic Criteria for Binge Eating Disorder

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 three (or more) 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 behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Binge eating disorder is different from bulimia in two main ways:

People with binge eating disorder do not persistently try to compensate for the binges; for instance, they don’t purge or compulsively exercise.
Most people with binge eating disorder are obese; people with bulimia generally range in weight from somewhat underweight to overweight but are not generally obese (Grucza et al., 2007; Hudson et al., 2007).

People with binge eating disorder are also more likely to develop medical problems as a result of their nutritional intake, such as diabetes, high blood pressure, high cholesterol, and heart disease. (Binges are typically high in fats, sugars, and/or salt, as was the case for the woman in Case 10.4.) Research suggests that the gender difference typical of other eating disorders is less pronounced with binge eating disorder. This disorder is more common than anorexia nervosa and bulimia nervosa combined (Grucza et al., 2007; Hudson et al., 2007). TABLE 10.6 contains additional facts about binge eating disorder.

Table : TABLE 10.6 • Binge Eating Facts at a Glance

Prevalence

During their lifetime, 4–5% of Americans will develop binge eating disorder; it is more prevalent than anorexia and bulimia combined.
Up to 30% of people seeking weight loss treatments have binge eating disorder (Hudson et al., 2007).

Comorbidity

Almost 80% of people with binge eating disorder also have another psychological disorder (Hudson et al., 2007).

Onset

Binge eating disorder typically begins when people are in their 20s (Kessler et al., 2013).
The onset of binge eating is often followed by strenuous dieting.

Course

Left untreated, people with binge eating disorder may cycle through periods of dieting followed by bingeing and weight gain.

Gender Differences

Almost twice as many women as men will be diagnosed with binge eating disorder.

Cultural Differences

In the United States, binge eating disorder is more common among Latinos and African-Americans than Whites (Marques et al., 2011).

Source: Unless otherwise noted, the source for information is American Psychiatric Association, 2013.

306

CASE 10.4 • FROM THE OUTSIDE: Binge Eating Disorder

The 48-year-old African-American woman described below sought treatment for her binge eating disorder.

The patient reported an onset of “eating binges” at approximately age 16. The binge eating began soon after she began babysitting for neighborhood children. […] During those times she would “load up on junk food” that the family had provided. She recalled that she would eat chips, cookies, and brownies “non-stop,” and that these eating episodes often lasted throughout the evening. She recalled feeling a loss of control during these episodes and stated that she would continue to eat despite not feeling physically hungry and that she would not stop until feeling physically ill. She reported that she was very embarrassed and secretive about these eating behaviors. […] She denied any history of extreme inappropriate weight control or purging behaviors such as self-inducing vomiting or misusing laxatives.

Around 6 months ago her binge eating increased in frequency to three to four times per week during her mother’s illness, and increased to six to seven times per week following her mother’s death […] The patient described her typical binge episode as starting with an evening meal and extending for several hours […when] she would then eat the “leftovers” while cleaning up after the meal, such that overall she would have consumed the equivalent of two full meals. She would then eat various foods throughout the rest of the evening until bedtime. During these episodes, she would alternate between salty and sweet snacks.

(White et al., 2010, p. 12)

307

CURRENT CONTROVERSY

Is Binge Eating Disorder Diagnosis a Good Idea?

When using DSM-IV, clinicians and researchers ended up evaluating a significant number of people who had disordered eating but whose symptoms did not fully meet the necessary criteria for bulimia or anorexia—the only two eating disorders in that edition. But because the symptoms nonetheless caused significant distress or impaired functioning, such patients received the diagnosis eating disorder not otherwise specified, which was the nonspecific “other” diagnosis for the eating disorders category. In fact, more people received this “other” diagnosis than were diagnosed with anorexia or bulimia combined.

To address this problem, DSM-5 added the disorder binge eating disorder, which fit a subset of people with the “not otherwise specified” diagnosis. As noted in TABLE 10.5, the criteria for binge eating disorder involve more than simply overeating occasionally. But adding what is, in essence, out-of-control eating without “inappropriate” attempts to compensate for the calories is controversial.

On the one hand, some (Frances, 2013) criticize including this set of symptoms as a disorder. Although this type of overeating may feel bad—both physically and psychologically—it shouldn’t be its own disorder. If such behavior constitutes a disorder, then any other form of self-control problem that makes the person feel bad should be considered a psychological disorder.

On the other hand, if the binge eating were accompanied by purging, it would be considered to be bulimia. So purging—or the absence of it—should not be the key determinant of whether disordered eating is considered an eating disorder. Moreover, making binge eating disorder a “disorder” allows treatment to be eligible for payment by insurance companies.

CRITICAL THINKING Even if the pattern of symptoms in binge eating disorder sounds disordered, is it really enough to be considered a valid diagnosis? Should we call something a disorder just because being out of control in some way is distressing?

(James Foley, College of Wooster)

Disordered Eating: “Other” Eating Disorders

GETTING THE PICTURE

Imagine that you know that both of these women are afraid of getting fat and believe themselves to be overweight. If you had to guess based on their appearance, which of these models would you think didn’t meet all the criteria for anorexia nervosa and instead had a partial case? The woman on the right is more likely to have a partial case because, based on these photos, she does not appear to be significantly underweight.

Many adolescents and adults with significantly disturbed eating don’t meet all the criteria for anorexia, bulimia, or binge eating disorder; those people may be diagnosed with a nonspecific “other” eating disorder. In one study, one quarter of patients with an eating disorder had this type of diagnosis (Fairburn & Cooper, 2011).

Because this “other” type does not specify particular criteria, people who are given this diagnosis have a wide range in number, frequency, and duration of symptoms. Nevertheless, people with this “other” diagnosis often fall into one of two groups. One group consists of people with partial cases, meaning that their symptoms meet some of the diagnostic criteria for a specific disorder but not enough to justify the diagnosis of that disorder. An example of a partial case of binge eating disorder would be someone whose symptoms meet all the other criteria for the disorder but who does not eat quickly, eat alone, or eat when not hungry; she would thus be diagnosed with the nonspecific “other” eating disorder.

Another group consists of people with subthreshold cases; they have symptoms that fit all the diagnostic criteria for a specific disorder but at levels lower than required for the diagnosis of that disorder. For instance, such people may have had anorexia or bulimia but then improved to the point where their symptoms no longer meet the criteria for either disorder. Nevertheless, these people still have clinically significant symptoms of an eating disorder. This was true of Marya Hornbacher: As the symptoms of her eating disorder abated, she no longer met the criteria for either anorexia or bulimia, and her diagnosis would be changed to “other” eating disorder.

308

Thinking Like A Clinician

Tanya had been dieting, but after a month or so, she began to pig out toward bedtime. After the first few of these gorging sessions, she felt both physically uncomfortable and ashamed of herself, and she would make herself vomit. After about a week, though, she stopped throwing up; instead, she began exercising for about an hour each day. This pattern of daily exercising and pigging out in the evening has persisted for about 6 months. Does Tanya have bulimia nervosa, binge eating disorder, the nonspecific “other” eating disorder, or just disordered eating but no DSM-5 diagnosis? What were the key factors that determined your answer?

Partial cases Cases in which patients have symptoms that meet only some of the necessary criteria but not enough symptoms to meet all the necessary criteria for the diagnosis of a disorder.

Subthreshold cases Cases in which patients have symptoms that fit all the necessary criteria, but at levels lower than required for the diagnosis of a disorder.