International Journal of (2001), 25, Suppl 1, S51–S55 ß 2001 Nature Publishing Group All rights reserved 0307–0565/01 $15.00 www.nature.com/ijo PAPER disorder and obesity

M de Zwaan1*

1Department of General , University Hospital of Psychiatry, Vienna, Austria

Binge (BED) was included in the DSM IV as a proposed diagnostic category for further study and as an example for an eating disorder not otherwise specified (EDNOS). BED is characterized by recurrent episodes of binge eating in the absence of regular compensatory behavior such as vomiting or abuse. Related features include eating until uncomfortably full, eating when not physically hungry, eating alone and feelings of or guilt. BED is associated with increased psychopathology including depression and personality disorders. Although BED is not limited to obese individuals, it is most common in this group and those who seek help do so for treatment of rather than for binge eating. In community samples, the prevalence of BED has been found to be 2 – 5%, in individuals who seek weight control treatment the prevalence is 30%. BED is more equal in gender ratio than . Eating disorder treatments such as cognitive behavior therapy (CBT) or interpersonal (IPT) improve binge eating with abstinence rates of about 50%. are also effective in reducing binge eating, though less so than psychotherapy. Standard treatments including do not seem to exacerbate binge eating problems. Thus, both eating disorder and obesity treatments seem to be beneficial in BED. However, it is recommended today that treatment should first be directed at the and associated psychopathology. International Journal of Obesity (2001) 25, Suppl 1, S51 – S55

Keywords: binge eating; ;

Diagnosis BED is more equal in gender ratio5 (65% female, 35% male) Although Albert Stunkard in 19551 identified binge eating as than bulimia nervosa (BN), for which only about 10% of a distinct eating pattern in some obese individuals, this persons affected are men.5 BED is more common among phenomenon received little systematic attention until a overweight women seeking treatment than overweight few years ago. Preliminary criteria for a disorder, termed women not seeking treatment. Approximately 30% of binge eating disorder (BED) in DSM IV2 has been delineated those participating in weight loss programs and 70% of in an attempt to better define and study this problem. This individuals in display BED.4 Inter- newly conceptualized eating disorder has been given provi- estingly, in a community survey only half of the BED sub- sional status by being included in the Appendix of the DSM jects were obese (BMI > 27.5 kg=m2) and only about 5% of IV2 for diagnostic categories meriting further study, and is the obese subjects met BED criteria.3 Consequently, this also included as an example of eating disorders not other- problem behavior seems to be significantly less prevalent wise specified (EDNOS). The diagnostic criteria currently in obese subjects not currently in treatment (Table 2). recommended for BED are presented in Table 1. It is important to keep in mind that in clinical settings the great majority of persons with BED will have varying degrees of obesity, even though the diagnosis is not limited to over- weight individuals. Course Prolonged periods without binge eating seem to be rare, at least in the weight control samples investigated thus far.4 In Prevalence a community sample of young women with BED the diag- The community surveys have estimated the current preva- nosis was less stable. After an observation period of 5 years lence of binge eating disorder to be between 2 and 5%.3,4 just 10% still met the criteria for BED.6 The binge episodes of overweight individuals seem to differ in important ways from the binge episodes described *Correspondence: M de Zwaan, Department of General Psychiatry, Wa¨hringer Gu¨rtel 18-20, A-1090 Vienna, Austria. by patients with BN. BED subjects consume approximately E-mail: [email protected] half the calories of those with BN during binges and they Binge eating disorder and obesity M de Zwaan S52 Table 1 Proposed diagnostic criteria for binge eating disorder that binge eating obese have an earlier onset of obesity than nonbinge eating obese, start at an earlier age, start (A) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: worrying about their weight at an earlier age, report a higher prevalence of marked weight fluctuations in the past, and (1) Eating, in a discrete period of time (eg within any 2 h period), an amount spend more time during adulthood trying to lose weight.18,19 of food that is definitely larger than most people would eat during a similar period of time under similar circumstances. (2) A sense of lack of control during the episodes (eg a feeling that one cannot stop eating or control what or how much one is eating.

(B) The binge eating episodes are associated with at least three of the Metabolic characteristics following behavioral indicators of loss of control: Few studies have investigated physiological differences (1) Eating much more rapidly than usual. between obese individuals with and without BED. There is (2) Eating until feeling uncomfortably full. no evidence that obese subjects with BED are more prone to (3) Eating large amounts of food when not feeling physically hungry. medical consequences of obesity than obese subjects without (4) Eating alone because of being embarrassed by how much one is eating. BED if one controls for weight. No significant differences (5) Feeling disgusted with oneself, depressed or feeling very guilty after . were observed in blood pressure, resting metabolic rate (RMR), resting energy expenditure (REE), body fat distribu- (C) Marked distress regarding binge eating. = (D) The binge eating occurs, on average, at least 2 days a week for a 6 month tion (waist hip ratio), percentage body fat, and blood serum period.a measures such as glucose, insulin levels, lipid levels, and (E) The binge eating is not associated with the regular use of inappropriate thyroid hormones.20 Others did not find an association compensatory behaviors (eg purging, fasting, excessive exercise) and does between binge eating severity and glycemic control in not occur exclusively during the course of anorexia nervosa or bulimia 12 nervosa. obese patients with type 2 .

aWithout purging behavior it is sometimes difficult to label binge eating episodes. Consequently, the diagnostic criteria for BED focus on days in which binge eating episodes occurred rather than on specific numbers of episodes. Psychopathology Most investigations found significantly higher levels of eating related and general psychiatric symptomatology in also binge less frequently.5 In line with data on BN subjects, obese patients with binge eating than those without binge obese binge eaters appear to increase their intake of fat rather eating,20 – 22 but significantly lower values compared with than carbohydrates.7 bulimic patients.23 In most studies there appears to be a There is no evidence that in obese patients binge eating is a positive relationship between binge eating and depressive result of dietary restraint.8–10 About half of the patients with symptoms as well as a lifetime history of affective disorders BED start binge eating first in the absence of dieting.11 – 13 in samples recruited for treatment trials but also, probably to Consequently, disinhibition rather than dietary restraint a lesser degree, in non-treatment-seeking samples of obese seems to precipitate binge eating in many obese subjects.5 BED women (Table 3). Regarding clinical implications, Negative emotional states such as anger and frustration, depressive symptomatology may render individuals more depression and , a nonspecific feeling of tension14 vulnerable to the development of binge eating but also to social situations, time of day, and the type of meal have been binge eating relapse after treatment. Treatment should, reported to trigger bingeing in BED.15 Emotions following a therefore, target the relation between binge eating and binge are usually negative, with guilt, regret, disgust and self- depression. loathing evident.16

Weight Risk factors There seems to be a positive correlation between binge Fairburn et al24 compared putative risk factors preceding the eating severity and the degree of obesity.17 There is evidence onset of BED in 52 women with BED, 104 without an eating disorder, 102 with other psychiatric disorders, and 102 with Table 2 The prevalence of binge eating disorder BN. BED appears to be associated with exposure to risk factors

Community samples 2 – 5% for psychiatric disorders (eg negative self-evaluation, parental Percentage overweight 50% depression, adverse childhood experiences including sexual Percentage of those overweight 5% and physical abuse and a range of parental problems, and Gender distribution (f:m) 65:35 pregnancy before onset) and with exposure to risk factors for similar prevalence of BED among racial groups obesity (eg , critical comments by family Participants in weight control programs 16 – 30% about shape, weight or eating). However, compared with BN Overeaters Anonymous 70% the risk factors for BED are weaker. Even vulnerability to obesity Prior to bariatric surgery 33 – 47% seems to be more pronounced in BN.

International Journal of Obesity Binge eating disorder and obesity M de Zwaan S53 Table 3 Lifetime prevalence rates of axis I disorders using structured clinical interviews in obese binge eaters (studies comparing obese binge eaters with obese nonbinge eaters)

Authors Any Axis I diagnosis Affective disorder Substance use disorder

Hudson et al 39 —91.%* 21.%17.% Marcus et al 40 60.%* 32.%* 12.%20.% de Zwaan et al 15 72.%55.%—46.% Yanovski et al 22 60.%* 51.%* 12.%9.%* (major depression) (panic disorder) Brody et al 8 42.%33.%8.%— Specker et al 21 72.%* 49.%* 28.%12.% Mussell et al 41 70.%* 50.%* 23.%* 19.% Telch and Stice 42 59.%* 49.%* 15.%12.% (major depression) (alcohol) (panic disorder)

#Non-treatment-seeking sample. *Significantly higher values compared to nonbinge eating control groups. Adapted from Mussell et al 41 and de Zwaan.43

Treatment apy. However, withdrawal of drug treatment is frequently Treatment should target eating behavior and associated followed by immediate relapse.29 In addition, attrition rates psychopathology, weight and psychiatric symptomatology. are generally higher for the trials (23 – 54% with a mean attrition rate of 31%) than for the psychotherapy trials of BED (16 – 35% with a mean attrition rate of 14%).26 Psychotherapy Medication does not add to the effectiveness of CBT in Cognitive behavior therapy (CBT) and interpersonal psy- reducing binge eating.30 However, AD medication may chotherapy (IPT) are successful in reducing binge eating enhance weight loss beyond the effects of CBT.31 Hudson frequency in the short-term.25 Patients are usually treated et al32,33 state that antidepressants should be considered as as outpatients in a group format. Subjects treated with CBT an option in all patients with BED and should be strongly show reductions in the number of episodes of binge eating considered in those who fail to respond to psychological and abstinence rates from 48 to 98% and 28 to 79%, treatments. The authors propose to start with an SSRI respectively. In contrast waiting list control groups exhibit (eg fluvoxamine, fluoxetine) and, if necessary, to conduct reductions of binge eating and abstinence rates ranging from sequential trials of antidepressants (eg desipramine, imipra- 9 to 22% and 0 to 9%, respectively.26 However, many sub- mine) to achieve a good result. jects resume binge eating after completion of treatment. Fichter et al27 reported the results of a 6 y follow-up of 68 obese BED patients after intensive inpatient treatment. The Self-help disturbed eating behavior as well as general psychopathology Although psychotherapy has been found to be beneficial in improved significantly in obese binge eaters and remained reducing binge eating symptoms, this type of intervention is stable during follow-up. At follow-up, the majority showed costly in the treatment of eating disorders and may be no major DSM-IV eating disorder, 5.9% still had BED, 7.4% unnecessarily intensive for some individuals with BED. had shifted to BN purging type, 7.4% were classified as Self-help may facilitate the dissemination of treatment to a EDNOS, and one patient had died. wider population of individuals who need it. With regard to weight, reduction of binge eating through There are now first results also in patients with BED using short-term psychotherapy results in only modest weight loss, various modes of service delivery, eg group format with if any. However, individuals who stop binge eating during videotapes,34 in-person on a one-to-one basis,35,36 and even CBT lose more weight than those who do not. BED subjects by telephone.37 The results show a marked reduction in who stop binge eating during CBT are usually successful in binge eating frequency as well as improvement in secondary maintaining their weight. This suggests that treating the outcome measures. Abstinence rates of 40 – 50% could be eating disorder first and then treating the overweight is a achieved after 8 – 12 weeks of working with a self-help logical approach to the management of the overweight binge manual or book.36 This result could be maintained over a eater.28 6 month follow-up period.

Antidepressant medication Weight loss treatments Antidepressants are successful in reducing binge eating fre- The clinical reality is that these patients want and seek quency in the short term, though less so than psychother- treatment for weight loss. In weight reduction treatments

International Journal of Obesity Binge eating disorder and obesity M de Zwaan S54 the amount of weight lost does not differ between binge 12 Herpertz S, Albus C, Wagener R, Kocnar M, Wagner R, Henning A, Best F, Foerster H, Schulze Schleppinghoff B, Thomas W, Ko¨hle K, eating obese and nonbinge eating obese. There are studies Mann K, Senf W. Comorbidity of diabetes mellitus and eating showing greater attrition and faster weight regain in BED disorders: does diabetes control reflect disturbed eating behavior? subjects than in non-BED subjects. However, most studies on Diabetes Care 1998; 21: 1110 – 1116. the use of weight loss programs found that binge eating did 13 Bulik MB, Sullivan PF, Carter FA, Joyce PR. Initial manifestations of disordered eating behavior: dieting versus binging. Int J Eat not affect weight regain, adherence to the , or attrition. Disord 1997; 22: 195 – 201. There is even evidence for lower attrition rates in binge 14 Stice E, Akutagawa D, Gaggar A, Agras WS. Negative affect eating subjects. moderates the relation between dieting and binge eating. Int J Weight loss treatments including bariatric surgery do not Eat Disord 2000; 27: 218 – 229. 15 de Zwaan M, Nutzinger DO, Schoenbeck G. Binge eating in exacerbate binge eating problems, but are associated with overweight women. Comp Psychiat 1992; 33: 256 – 261. short-term reductions in binge eating. Thus, there is no 16 Arnow B, Kenard, J, Agras WS. Binge eating among the obese: a reason to exclude obese BED patients from weight loss descriptive study. J Behav Med 1992; 15: 155 – 170. programs.38 However, studies focusing on weight reduction 17 Bruce B, Agras WS. Binge eating in females: a population-based investigation. Int J Eat Disord 1992; 12: 365 – 373. are always confronted with the well-known problem of 18 de Zwaan M, Mitchell JE, Seim HC, Specker SM, Pyle RL, obesity being associated with high attrition rates and poor Raymond NC, Crosby RB. Eating related and general psycho- long-term maintenance of weight reduction. pathology in obese females with binge eating disorder (BED). It is generally recommended today that in obese binge Int J Eat Disord 1994; 15: 43 – 52. 19 Mussell MP, Mitchell JE, Weller CL, Raymond NC, Crow SJ, eaters treatment should first be directed at the disordered Crosby RD. Onset of binge eating, dieting, obesity, and mood eating and associated psychopathology. Interventions direc- disorders among subjects seeking treatment for binge eating ted at the psychopathology associated with BED could disorder. Int J Eat Disord 1995; 17: 395 – 401. reduce the influence of emotional cues on binge eating. An 20 Wadden TA, Foster GD, Letizia KA, Wilk JE. Metabolic, anthro- pometric, and psychological characteristics of obese binge eaters. approach to BED with obese patients would be first to Int J Eat Disord 1993; 14: 17 – 25. bring the eating disorder under control, and only then to 21 Specker S, de Zwaan M, Raymond N, Mitchell J. Psychopathology consider additional weight reduction methods to address the in subgroups of obese women with and without binge eating remaining obesity. disorder. Comp Psychiat 1994; 25: 185 – 190. 22 Yanovski SZ, Nelson JE, Dubbert BK, Spitzer RL. Association of binge eating disorder and psychiatric comorbidity in obese sub- jects. Am J Psychiat 1993; 150: 1472 – 1479. 23 Raymond N, Mussell M, Mitchell J, Crosby R, de Zwaan M. An age-matched comparison of subjects with binge eating disorder References and bulimia nervosa. Int J Eat Disord 1995; 18: 135 – 143. 1 Stunkard AJ, Grace WJ, Wolff HG. The night-eating syndrome: a 24 Fairburn CG, Doll HA, Welch SL, Hay PJ, Davies BA, O’Connor pattern of food intake among certain obese patients. Am J Med ME. Risk factors for binge eating disorder. A community-based, 1955; 19: 78 – 86. case-control study. Arch Gen Psychiat 1998; 55: 425 – 432. 2 American Psychiatric Association. Diagnostic and statistical manual 25 Wilfley DE, Frank MA, Welch R, Spurrell EB, Rounsaville BJ. of mental disorders. DSM-IV. APA: Washington, DC; 1994. Adapting interpersonal psychotherapy to a group format (IPT-G) 3 Spitzer RL, Devlin M, Walsh BT, Hasin D, Wing R, Marcus M, for binge eating disorder. Toward a model for adapting empirically Stunkard A, Wadden T, Yanovski S, Agras S, Mitchell J, Nonas C. supported treatments. Psychother Res 1998; 8: 379 – 391. Binge eating disorder, a multisite field trial of the diagnostic 26 Wilfley DE, Cohen LR. Psychological treatment of bulimia ner- criteria. Int J Eat Disord 1992; 11: 191 – 203. vosa and binge eating disorder. Psychopharm Bull 1997; 33: 437 – 4 Spitzer RL, Yanovski S, Wadden T, Wing R, Marcus MD, Stunkard 454. A, Devlin M, Mitchell J, Hasin D, Horne RL, Binge eating disorder: 27 Fichter M, Quadflieg N, Gnutzmann A. binge eating disorder: its further validation in a multisite study. Int J Eat Disord 1993; 2: treatment outcome over a 6-year course. J Psychosom Res 1998; 44: 137 – 153. 385 – 405. 5 Castonguay LG, Eldredge KL, Agras WS. Binge eating disorder: 28 Agras WS, Telch CF, Arnow B, Eldredge K, Wilfley DE, Reaburn current state and future directions. Clin Psychol Rev 1995; 15: SD, Henderson J, Marnell M. Weight loss, cognitive-behavioral, 865 – 890. and desipramine treatments in binge eating disorder. An additive 6 Fairburn CG, Cooper Z, Doll HA, Norman P, O’Connor M. The design. Behav Ther 1994; 25: 225 – 238. natural course of bulimia nervosa and binge eating disorder in 29 Craighead LW, Stunkard AJ, O’Brian RM. Behavior therapy and young women. Arch Gen Psychiatry 2000; 57: 659 – 665. pharmacotherapy for obesity Arch Gen Psychiatr 1981; 38: 763 – 7 Yanovski SZ, Leet M, Yanovski JA, Flood M, Gold PW, Kissilieff 767. HR, Walsh BT. Food selection and intake of obese women with 30 Marcus MD, Wing RR, Ewing L, Kern E, McDermott M, bing-eating disorder. Am J Clin Nutr 1992; 56: 975 – 980. Gooding W. A double-blind, placebo-controlled trial of fluox- 8 Brody MJ, Walsh BT, Devlin MJ. Binge eating disorder: reliability etine plus behavior modification in the treatment of obese and validity of a new diagnostic category. J Consult Clin Psychol binge-eaters and non-binge eaters. Am J Psychiat 1990; 147: 1994; 62: 381 – 386. 876 – 881. 9 Marcus MD Wing RR Lamparski DM. Binge eating and dietary 31 Laederach-Hofmann K, Graf C, Horber F, Lippurner K, Lederer S, restraint in obese patients. Addict Behav 1992; 10: 163 – 168. Michel R, Schneider M. Imipramine and diet counseling with 10 Marcus MD, Smith DE, Santelli R, Kaye W. Characterization of psychological support in the treatment of obese binge eaters: a eating diordered behavior in obese binge eaters. Int J Eat Disord randomized, placebo-controlled double-blind study. Int J Eat 1992; 12: 249 – 255. Disord 1999; 26: 231 – 244. 11 Malkoff SB, Marcus MD, Grant A, Moulton MM, Vayonis C. The 32 Hudson JI, Carter WP, Pope HG. treatment of relationship between dieting and binge eating among obese binge-eating disorder: research findings and clinical guidlines. individuals. Ann Behav Med 1993; 15: S40. J Clin Psychiat 1996; 57: 73 – 79.

International Journal of Obesity Binge eating disorder and obesity M de Zwaan S55 33 Hudson JI, McElroy SL, Raymond NC, Crow S, Keck PE, Carter 39 Hudson JI, Pope HG, Wurtman J, Yurgelun-Todd D, Mark S, WP, Mitchell JE, Strakowski SM, Pope HG, Coleman B, Jonas JM. Rosenthal NE. Bulimia in obese individuals, Relationship to Fluvoxamine in the treatment of binge eating disorder. Am normal-weight bulimia. J Nerv Ment Disord 1988; 176: 144 – 152. J Psychiat 1998; 155: 1756 – 1762. 40 Marcus MD, Wing RR, Ewing L, Kern E, Gooding W, McDermott 34 Peterson CB, Mitchell JE, Engbloom S, Nugent S, Mussell MP, M. Psychiatric disorders among obese binge eaters. Int J Eat Disord Miller JP. Group cognitive behavioral treatment of binge eating 1990; 9: 69 – 77. disorder: a comparison of therapist-led versus self-help formats. 41 Mussell M, Mitchell J, de Zwaan M, Crosby RD, Seim HC, Crow SJ. Int J Eat Disord 1998; 24: 125 – 136. Clinical characteristics associated with binge eating in obese 35 Fairburn CG. Overcoming binge eating. Guilford Press: New York; females: a descriptive study. Int J Obes Relat Metab Disord 1996; 1995. 20: 324 – 331. 36 Carter JC, Fairburn CG. Cognitive-behavioral self-help for binge 42 Telch CF, Stice E. Psychiatric comorbidity in women with binge eating disorder: a controlled effectiveness study. J Consult Clin eating disorder: prevalence rates from a non-treatment-seeking Psychol 1998; 66: 616 – 623. sample. J Consult Clin Psychol 1998; 66: 768 – 776. 37 Wells AM, Garvin V, Dohm FA, Striegel-Moore RH. Telephone- 43 de Zwaan M. Status and utility of a new diagnostic category: based guided self-help for binge eating disorder: A feasability Binge eating disorder. Eur Eat Dis Rev 1997; 5: 226 – 240. study. Int J Eat Disord 1997; 21: 341 – 346. 38 Alger SA, Malone M, Cerulli J, Fein S, Howard L. Beneficial effects of pharmacotherapy on weight loss, depressive symptoms, and eating patterns in obese binge eaters and non-binge eaters. Obes Res 1999; 7: 469 – 476.

International Journal of Obesity