Binge Eating Disorder: Recognition, Diagnosis, and Treatment

Timothy D. Brewerton, MD

Disclosures

Medscape Psychiatry & Mental Health eJournal. 1997;2(3) 

In This Article

Classification and Diagnosis

Binge eating disorder (BED) has been proposed as a diagnostic entity and is now listed in the appendix of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).[1,2,3,4,5,6] BED is defined by recurrent episodes of binge eating at least 2 days a week for at least 6 months. In addition, there is a subjective sense of a loss of control over binge eating, which is indicated by the presence of 3 of 5 specific criteria. These include eating rapidly, eating when not physically hungry, eating when alone, eating until uncomfortably full, and feeling self-disgust about bingeing.

Albert Stunkard[7,8] first described binge eating in a subset of obese patients and coined the term "night eating syndrome" (NES), which is similar to but distinct from BED. The newer, evolved concept of BED does not have the nocturnal component as a requirement. In NES, binge eating occurs nocturnally and is followed by morning anorexia and food restriction, which is thought to contribute to the next cycle of overeating. Other unofficial but related terms have appeared in the literature to describe individuals with binge eating not complicated by purging, such as "obese binge eaters" or "compulsive overeaters."[9,10,11] Kornhaber[12] described the "stuffing syndrome" in 1970. Since the publication of the DSM-III in 1980, these individuals have been officially, yet nonspecifically, classified as having an "eating disorder not otherwise specified (EDNOS).[13]

The first acknowledgment of binge eating in American psychiatry's diagnostic classification system occurred in the DSM-III; designated "bulimia," it encompassed not only bingeing but purging and preoccupation with body shape and weight as well. The revised edition of the DSM-III (DSM-III-R), published in 1987, adopted the term "bulimia nervosa,"[14] which was coined by Gerald Russell in 1979. Russell conceptualized this syndrome as "an ominous variant of anorexia nervosa."[15] Binge eating per se, without counteractive weight-reducing behaviors, was not identified as a major psychiatric disorder or problem until the recent inclusion of BED in the DSM-IV appendix.[1]

As our knowledge base about psychiatric disorders in general has increased over the years, our diagnostic classification system has evolved to describe them more accurately. Within this overall process, the eating disorders have only recently received serious research interest. The inclusion of nonpurging binge eating as an illness is a natural extension of this evolving process. Like bulimia first, and then bulimia nervosa, the diagnostic classification of BED will allow this group of patients to be further studied from a clinical research perspective and also to receive more accessible and appropriate treatment. In my view, BED depicts a serious psychologic problem that has been heretofore underrecognized and undertreated. However, the exact boundaries of BED remain to be further clarified, and it is likely that the criteria will continue to evolve as our knowledge base increases.

One of the major controversies regarding the diagnosis of BED includes its differentiation from nonpurging bulimia nervosa as currently defined in DSM-IV.[16] Nonpurging bulimia nervosa involves fasting and excessive exercise as compensatory behaviors, as well as preoccupation with body shape and weight.[1] However, the similarities between these 2 conditions appear to outweigh their relatively minor behavioral differences. In clinical practice, these disorders tend not to be distinct entities but exist on a continuum. Patients also go in and out of the criteria over time. It is very difficult clinically to distinguish between what are appropriate weight loss measures to combat obesity versus the excessive amount of counteractive exercise that characterizes nonpurging bulimia nervosa. In addition, both obese bingers[17,18] and BED patients have been reported to have similar attitudes about body weight and shape, as compared with both nonpurging[19] and purging bulimia nervosa patients.[20] Regardless of the appellation, it is clear from epidemiologic studies that a meaningful number of patients have clinically significant binge eating and related psychopathology, not complicated by purging, that warrants treatment.

In the laboratory, BED patients have been shown to eat significantly more calories during a binge meal than non-BED obese patients.[21,22] (Simple obesity is defined as a BMI>=30). Dietary restraint and/or disinhibition appear to play major roles in triggering binge episodes.[23,24,25]

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