A Clinician’s Guide to Binge Eating Disorder

An edited version of the Foreword to A Clinician’s Guide to Binge Eating Disorder:

BED has been recognized as a provisional eating disorder for several years and has been recommended for inclusion in DSM-5 as a diagnostic category in its own right. Nonetheless, there continue to be a number of important questions regarding the fundamental nature of the disorder. Its name suggests that eating behavior, specifically binge eating, unaccompanied by the compensatory behaviors that characterize bulimia nervosa, lies at its core. Yet patients who present for treatment often display a cluster of symptoms along different dimensions including behavioral features (binge eating, frequent dieting), somatic features (weight gain leading  to  overweight  or  obesity, unstable weight), and psychological features (negative affect, body shape/weight overconcern), and, while the precise causal relationships among these features are far from clear, there are a number of potential relationships.

The pattern of episodic overconsumption accompanied by a feeling of loss of control (loC) may be profoundly distressing and may increase the individual’s attention  to  and distress  regarding  weight and shape. in a reciprocal fashion, negative emotion, e.g. sadness, shame, or anxiety, which at various times may or may not be related to body image distress, can provoke binge eating. For many people, dieting represents an attempt to remedy this distress, but often fails to be sustained, leading to a resurgence of binge eating. Although not represented on the diagram, many would argue that dieting may additionally serve to amplify and sustain body image over-concern. overconsumption may lead to weight gain, which in turn leads to intensified negative affect, particularly related to weight and shape, and promotes further binge    eating.

While the general features of BED are relatively well established, important unanswered questions arise on closer examination. one such question relates to the “anatomy of a binge”. BED is defined in DSM-iv-Tr Appendix B in an identical fashion to the binge eating episode in bulimia nervosa (Bn), with the two key features of ingesting an objectively large amount of food and experiencing a sense of lack of control. However, it is not clear that typical binge eating episodes in BED, which unlike binge eating episodes in Bn are not punctuated by attempts at compensation via purging, exercise, or fasting, resemble typical binge eating episodes in Bn. The relationships among negative emotion, cognitions regarding control or lack thereof, and actual and perceived amount consumed have yet to be fully elucidated. An important question for both BED and Bn is whether the two defining features of an eating binge, i.e. objectively large amount of food and sense of lack of control, are equally important. For both disorders, it has been suggested that people who report only subjective eating binges, i.e. sense of lack of control without the consumption of an objectively large amount of food, in many ways resemble those who consume objectively large amounts of food during their eating binge (Wolfe et al. 2009). Despite this resemblance, it is possible that, particularly for people with BED who do not engage in compensatory behaviors, the outcome of recurrent objective binge eating may differ from that of subjective binge eating; specifically, objective binge eating may be more conducive to weight gain.

Beyond the question of whether binge size matters, the broader question of what exactly takes place during an eating binge is a more complex question than may initially be apparent. The complexities of assessment are ably reviewed in Chapter 9, and, upon careful review of the various methodologies that have been developed, it is clear that all have their limitations. research methodologies, including laboratory studies, i.e. observed meals under instructions to engage in or avoid binge eating, and ecological momentary assessment (EMA), i.e. inter- mittent reporting via handheld computer, of real-life eating behavior and related experience, also have their limitations. It is apparent that, like the blind men and the elephant, only through ongoing study from a variety of vantage points, making use of different self-report, interview, laboratory, EMA, and perhaps other measures yet to be developed, will we be able to come to a full and accurate understanding of the nature and experience of the eating binge.

Another important question regarding BED concerns its relationship with obesity, reviewed in Chapter 1. Although obesity is not a criterion for the BED diagnosis, BED and obesity are often grouped together in the minds of patients and professionals alike, raising questions regarding the centrality of obesity or the potential for obesity in the diagnostic construct. For patients with both BED and obesity, the nature of the causal associations, if any, are unclear. in other words, it is theoretically possible that binge eating may contribute to the development of obesity, or be reinforced by a pattern of intermittent strict dieting, or both of the above. It is also possible that the genetic and environmental risk factors (see Chapter 3) that contribute to the risk for obesity and BED may be partially but not fully overlapping. regardless of the theoretical relationship between BED and obesity, most people who present for treatment for BED are overweight or obese, and it may be important to take the presence of binge eating into account when initiating treatment for obesity, whether this involves behavioral weight loss (see Chapter 15), bariatric surgery (see Chapter 14), or other approaches.

During the past two decades, along with defining the central features of BED and developing reliable methods to assess these features, we have begun to learn about additional characteristics of those who suffer from this disorder. Given the intense and varied cultural meanings of food and body size and shape, it is not surprising that ethnicity and race may influence the risk for and particular expression of BED. These factors, including their interaction with age, gender, socioeconomic status, and other demographic features, are comprehensively presented in Chapter 2. one of the most consistently reported findings in the literature on BED is the increase in comorbid psychological symptoms, particularly in depression, in those with BED compared to otherwise similar individuals who do not binge eat (see Chapters 4 and 5). The multifaceted concept of body image disturbance is explored in Chapter 6, including its behavioral, perceptual, cognitive, and emotional components. it is of note that body image disturbance, so central to the experience of many who engage in binge eating, is not currently a BED diagnostic criterion, and questions regarding whether it should be regarded as part of the core construct of BED or simply as a frequently associated feature are the subject of ongoing investigation.

As important as questions regarding diagnostic features and etiology of BED may be, the most immediately compelling questions, particularly for those who suffer from BED, involve treatment. Treatment, of course, rests on an under- standing of the causal factors that give rise to and, perhaps more importantly, maintain the disorder, and theories regarding initiating and maintaining factors are often inspired by analogies with related conditions. It is not surprising, given that BED is primarily characterized by a disorder of eating and that many patients who present for treatment of BED are overweight or  obese,  that  treatments have largely derived from treatments for eating disorders, particularly Bn, and for obesity. Psychological interventions including cognitive behavioral therapy (CBT), interpersonal therapy (iPT), dialectical behavior therapy (DBT) have shown great promise, and, as reviewed in Chapters 10 and 11, we are beginning to appreciate features that might allow the therapist to rationally select among these options. it is important to note that, in an age of escalating health care costs and diminishing resources, guided and pure self-help approaches have proven to be an effective and less costly alternative for some. As is the case for Bn, medication may serve a useful adjunctive role for many patients with BED (Chapter 12).

While the person who called the eating disorders clinic for help in our opening example had tried weight control programs without success, there is in fact evidence that treatment approaches based on weight control treatment, including behavioral weight loss (Chapter 15) and bariatric surgery (Chapter 14), may be helpful for patients with BED who are overweight or obese and consider weight loss to be one of their goals. our ever-increasing experience and knowledge base regarding BED has allowed these approaches to be tailored to manage the particular needs and problems of people with BED. Perhaps the most important example of an approach that re-conceptualizes the treatment based on the particular needs of individual patients with loC eating and body image disturbance is intuitive eating and movement (iEM) reviewed in Chapter 16. However, regardless of the treatment approach, recognition of the ways in which treatment approaches evolve over time and in different contexts underscores the point that generalizations regarding  various treatment approaches must be  tempered by recognition of the ways in which the approach is operationalized in a particular setting with a particular patient population.