European Eating Disorders ReviewEur. Eat. Disorders Rev. 8, 340Ð343 (2000)

European Eating Disorders ReviewCopyright �c 2000 John Wiley & Sons, Ltd and Eating Disorders Association. 8(5), 340Ð343 (2000)

Special SectionBinge Eating and Binge Eating Disorder

Ulrike Schmidt*Eating Disorders Unit, South London and Maudsley NHS Trust, DenmarkHill, London SE5 8AZ, UK

BACKGROUND

Although binge eating in the obese was first described by Stunkard in 1959,a broader interest in this topic developed only in the 1980s largely promptedby the arrival of bulimia nervosa. After completion of the DSM-IV multisitefield trials (Spitzer et al., 1992, 1993) binge eating disorder (BED) wasincluded in the appendix in DSM-IV (1994) as a category ‘deserving furtherstudy’ rather than as a full syndrome. We are now in the run-up to DSM-V and ‘further study’ into BED is in full swing.

DEFINITIONS

The defining criteria of binge eating disorder are modelled on those forbulimia nervosa (BN) with additional criteria to produce a water-tightdefinition of loss of control and a more stringent frequency criterion, i.e. 6months of a minimum of two binge days per week. This definition covers abroad range of severity. At the mild end there are individuals who perhapsmay be a little plump, who overeat a couple of times a week and aredistressed about it. At the severe end, there are individuals crippled bymorbid obesity, who binge daily and who have a very high risk of dyingfrom their condition. Concerns about the diagnostic reliability of BED havebeen expressed, in particular about how to delineate the disorder from non-purging BN (Hay and Fairburn, 1998). Concerns about validity have resultedfrom a cluster analytic study (Hay et al., 1996), research on the disorder’spredictive validity (Hay and Fairburn, 1998; Fairburn, 1999) and a familystudy of the disorder (Lee et al., 1999). One study specifically examined thevalidity of the frequency criterion for binge eating and found few differencesbetween subthreshold and full-syndrome BED (Striegel-Moore et al., 1998).

* Correspondence to: Dr. Ulrike Schmidt, Eating Disorder Unit, South London and Maudsley NHSTrust, Denmark Hill, London SE5 8AZ, UK.

Eur. Eat. Disorders Rev. 8, 340Ð343 (2000) Binge Eating and BED

Despite these concerns, at the recent meeting of the Eating DisordersResearch Society in San Diego in November 1999 there seemed to be broadconsensus amongst key players in the field that there is sufficient researchevidence to support the usefulness of the diagnosis.

CLINICAL FEATURES

Typically, the onset of BED occurs in the teens or twenties. In weightreducing samples the female to male ratio is 3 : 2, whereas in communitysamples the sex ratio seems to be equal (Spitzer et al., 1992, 1993). About2Ð5% will have had a history of anorexia nervosa and 5Ð10% a history ofBN (see Agras, 1999). A lifetime history of psychiatric disorder is commonwith 50Ð70% of treatment seeking BED sufferers giving a history of majordepression, 70% of anxiety disorders and 25Ð30% of personality disorders;in non-treatment-seeking BED populations the rates are somewhat lower.

Whilst there are no gender differences in terms of eating disturbance,shape/weight concerns, interpersonal problems or self-esteem, men with BEDhave more lifetime psychiatric problems (Tanofsky et al., 1997).

Recently there has been a lot of interest in the order in which symptomsdevelop in BED. At least half report onset of bingeing before they startdieting, 35Ð45% diet first then binge and about 10Ð15% start bingeing anddieting simultaneously (e.g. Abbott et al., 1998). Those who binge first havea much earlier onset of bingeing (e.g. early teens versus mid-twenties) andreport post-binge reductions in anxiety. Whilst there do not seem to be anydifferences between binge-first and diet-first groups on current levels ofeating and weight disturbance, degree of overweight or psychological distress,the binge-first group report more life events, family problems and psychiatriccomorbidity, i.e. seem to be a more disturbed group.

COMPARING AND CONTRASTING BED, BN AND OBESITYIN VIVO AND IN VITRO

Compared to obese individuals without BED, those with BED and obesityhave an earlier onset and more severe obesity, more frequent weightfluctuations and more weight/shape-related distress. They also have lowerself-esteem, a higher lifetime prevalence of psychiatric disorder, in particulardepression and personality disorders, more commonly a history of treatmentfor emotional problems and greater impairment in work and social functioning(Spitzer et al., 1993; Striegel-Moore et al., 1998).

Compared to individuals with bulimia nervosa those with BED often startbingeing first, then diet; they also start bingeing earlier and have less dietary

Copyright �c 2000 John Wiley & Sons, Ltd and Eating Disorders Association. 341

U. Schmidt Eur. Eat. Disorders Rev. 8, 340Ð343 (2000)

restraint, less stringent slimness ideals, less body image problems and lesseror similar amounts of psychological distress and psychiatric comorbidity (e.g.Abbott et al., 1998; Agras, 1999).

Several feeding laboratory studies have compared bulimia nervosa, BEDand non-bingeing obese individuals. In BED the binge size is smaller thanin BN, BED patients eat more slowly during binges and overall their bingesresemble large normal meals. BN patients eat more carbohydrates and sugarand switch to desserts earlier (Walsh, 1999). Compared to obese non-bingersthose with BED show greater caloric intake during binges and non-bingemeals. Findings about the type of macro-nutrient preferred are inconsistent.Some feeding laboratory studies have used manipulations including short-term food deprivation, negative mood induction or both. These studies foundthat negative mood induction but not caloric deprivation led to subjectivebinges, whereas the combination of both led to objective binges.

Loss of control and distress about overeating are not the full story abouthow BED sufferers experience their binges. Mitchell et al. (1999) examinedthe hedonics of eating disorders comparing BED with bulimia nervosa.Whilst both groups were very similar in terms of their binge distress, andthe frequency and degree with which different binge precipitants wereendorsed, there were marked differences in terms of their responses to bingesand the concomitant binge experiences. BED sufferers often reported thatbingeing was making them relaxed, whereas those with BN reported that itwas making them anxious. BED sufferers also significantly more commonlyreported enjoying the food, its taste, smell and texture.

THE NATURAL COURSE OF BED

Looking at the natural course of binge eating disorder at 6Ð12 months (Hayet al., 1996; Agras, 1999) 30Ð50% continue to have BED; 30Ð50% have apartial remission and 10% are recovered. Stability in diagnosis is driven—at least in part—by associated psychopathology (Agras, 1999). At 5 years(Fairburn, 1999) only 9% still have BED, but there is a significant increasein rate of obesity.

CLINICAL UTILITY

BED, even if it is mild, may be useful as an early marker of later obesity.In cases of BED and established obesity, presence of the disorder flags upthe need for a multi-disciplinary approach to treatment. Lastly, having thisdiagnosis available should help clinicians to make better representations toour purchasers on behalf of this neglected patient group.

Copyright �c 2000 John Wiley & Sons, Ltd and Eating Disorders Association. 342

Eur. Eat. Disorders Rev. 8, 340Ð343 (2000) Binge Eating and BED

REFERENCES

Abbott DW, de Zwaan M, Mussell MP, Raymond NC, Seim HC, Crow SJ, CrosbyRD, Mitchell JE. 1998. Onset of binge eating and dieting in overweightwomen: implications for etiology, associated features and treatment. Journalof Psychosomatic Research 44: 367Ð374.

Agras S. 1999. Course of BED; classification among eating disorders: AN, BN, BEDand partial syndromes; treatment response: similarities and differencesamong BED and other EDs. Eating Disorders Research Society Annual Meeting,1999.

Fairburn CG. 1999. The predictive validity of binge eating disorder. Eating DisordersResearch Society Annual Meeting, 1999.

Hay P, Fairburn C. 1998. The validity of the DSM-IV scheme for classifying bulimiceating disorders. International Journal of Eating Disorders 23: 7Ð15.

Hay PJ, Fairburn CG, Doll HA. 1996. The classification of bulimic eating disorders:a community-based cluster analysis study. Psychological Medicine 26: 801Ð812.

Lee YH, Abbott DW, Seim H, Crosby RD, Mondson N, Burgard M, Mitchell JE.1999. Eating disorders and psychiatric disorders in the first-degree relativesof obese probands with binge eating disorder and obese non-binge eatingdisorder controls. International Journal of Eating Disorders 26: 322Ð332.

Mitchell JE, Mussell MP, Peterson CB, Crow S, Wonderlich SA, Crosby RD, DavisT, Weller C. 1999. Hedonics of binge eating in women with bulimianervosa and binge eating disorder. International Journal of Eating Disorders26: 165Ð170.

Spitzer RL, Devlin M, Walsh BT, Hasin D, Wing R, Marcus M, Stunkard A,Wadden T, Yanovski S, Agras S, Mitchell J, Nonas C. 1992. Binge eatingdisorder: a multisite field trial of the diagnostic criteria. International Journalof Eating Disorders 11: 191Ð203.

Spitzer RL, Yanovski S, Wadden T, Wing R, Marcus MD, Stunkard A, Devlin M,Mitchell J, Hasin D, Horne RL. 1993. Binge eating disorder: its furthervalidation in a multisite study. International Journal of Eating Disorders 13:137Ð153.

Striegel-Moore RH, Wilson GT, Wilfley DE, Elder KA, Brownell KD. 1998. Bingeeating in an obese community sample. International Journal of Eating Disorders23: 27Ð37.

Tanofsky MB, Wilfley DE, Spurrell EB, Welch R, Brownell KD. 1997. Comparisonof men and women with binge eating disorder. International Journal of EatingDisorders 21: 49Ð54.

Walsh T. 1999. Eating patterns among individuals with BED: laboratory studyfindings. Conclusions and summary recommendations. Eating DisordersResearch Society Annual Meeting, 1999.

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