A Clinician's Guide to Binge Eating Disorder

June Alexander, Andrea B. Goldschmidt, Daniel Le Grange, June Alexander, Andrea B. Goldschmidt, Daniel Le Grange

• Editorial: Routledge
• Año: 2013
• ISBN:
  9781135068578
• Edición: 1
• Categoría: Psicología
• Categoría: Psicología anormal

Incidence of BED appears to be on the increase. Treating it, and overcoming it, is all the more difficult, especially for those living in a culture that has an intense body image focus.

A Clinician's Guide to Binge Eating Disorder educates the reader about its triggers and behaviours – and describes steps to treat it and resume a full and productive life. Evidence-based research outcomes provide the framework and foundation for this book. First-person case studies bring application of this science to life to help close the gap between research and treatment/care, and the importance of clinicians developing a therapeutic relationship as a healing tool with their client is discussed, recognizing that medical and psychological dimensions are inextricably intertwined.

This book allays fear of the unknown, explains the emotional chaos that can sweep in like a storm when, unintentionally, triggers are released. It provides practical steps and footholds for clinicians and researchers to help the patient take control of their life and look to a positive future.

Part 1

The search for causes

Chapter 1

Binge eating disorder and obesity

Marney A. White and Loren M. Gianini

Case study

I didn’t start out overweight. When I was a kid, I was maybe a little on the “thick” side, but I was healthy. I was really active until adolescence, when I started to put on weight. That was when I started buying lunch at high school – which really meant that I started eating fast food and snack pies sold in the cafeteria. I would get either pizza or a fried chicken sandwich or a hamburger, and polish it off with a package of cupcakes. My friends and I went straight to the nearby fast food joint on the way home, too, and we would get French fries and dip them in ranch dressing. I remember that: French fries every day after school. When we started driving to and from school, my eating really started to get out of control. I was babysitting a lot on weekends, and the families were always really nice and would leave treats – cookies and chips and things – and tell me to just help myself. And I would. It got to the point that I even started ordering out while I was babysitting. I would have a pizza delivered, and I would eat all of it. I felt terrible afterward, and ashamed, and I remember sneaking the pizza box into the neighbors’ garbage can outside so that the family wouldn’t know what I had done. It was terrible.

When I went away to college, the bingeing got worse. I was on the college meal plan, and they had a full range of healthy foods available, but they also had the soft-serve ice cream at every meal, and an entire table full of cookies right there as you were exiting the cafeteria. So of course I usually grabbed one (or more!) on the way out. The thing about college food was that I felt so deprived. The cafeteria was only open for a few hours around each meal time, which never seemed to match up with my schedule. So I never made it there in time for breakfast (they stopped serving at 10am), and by lunchtime I was really hungry. They had this policy where you couldn’t take food “to go” – technically you weren’t supposed to leave with food at all – and since I knew that I would not be able to get food again until the cafeteria reopened for dinner, I would sort of “store up” and eat more than I really wanted. I was afraid of going hungry later. By the time I finished college, I was probably 20 or 30 pounds overweight.

I started dieting right after college, but never could stick with anything for long. I’ve tried every diet, and sometimes I’ve lost five or ten pounds, but I always gain it right back. Every day, I start out by telling myself that “THIS is the day. I’ll be good today. I can be good for a while.” Most days I can even make it all day long without eating anything. But then I’m so hungry that I eat a lot of food at night. I get depressed afterward, and usually end up just giving up.

My doctors, for years, have been telling me to lose weight. I’m trying, but I can’t lose it like everyone else can. I know that my health depends on it, and I really want to lose the weight! My doctors shake their heads and say: “You just need to eat less and exercise.” Don’t they know that’s what I’m trying to do? I guess I’m just a defective person.

Jamie, age 48

This case study demonstrates several important themes in understanding patients who struggle with binge eating disorder (BED). Most notably, BED is frequently associated with substantial weight gain, which can lead to obesity and various physical and psychological health problems. This chapter will focus on complications that arise due to concurrent obesity in BED, and will describe treatment approaches for the obese patient with BED.

Obesity is one of the leading and costliest health problems in the United States (US) and worldwide. The National Health and Nutrition Examination Survey (2007–2008) estimated that 68 per cent of the US population is overweight and 34 per cent is obese (Flegal et al. 2010). National annual medical costs associated with obesity were estimated to be over $75 billion (about 6 per cent of medical expenditures) (Finkelstein et al. 2004) in 2004, and due to the increasing prevalence of obesity these estimates had nearly doubled to $147 billion annually by 2009 (Finkelstein et al. 2009). These financial estimates do not include the treatment of obesity itself, but rather are generated based on costs of treating obesity-associated diseases. Worldwide, rates of obesity have more than doubled in the past three decades (World Health Organization 2011).

Health complications associated with obesity and BED

Discussion of the clinical features and treatment of BED must also consider obesity, since many people who suffer from this illness are obese (American Psychiatric Association 2000). Binge eating is strongly associated with increased obesity (Spitzer et al. 1992; Telch et al. 1988). Consequently, the health risks associated with obesity are relevant to most individuals with BED. Both BED and obesity are associated with a variety of medical complications, including non-insulin dependent diabetes mellitus, hypertension, and heart disease (Bray 1998; Bulik and Reichborn-Kjennerud 2003). However, compared to their non-binge eating obese counterparts (non-binge-eating obese, or ‘NBO’), people with BED experience more health problems (Hudson et al. 2007; Johnson et al. 2001; Kanter et al. 1992; Telch et al. 1988) and report greater dissatisfaction with their physical health (Bulik et al. 2002). Furthermore, compared to obese groups without binge eating, BED is associated with increased serious psychosocial problems and psychiatric difficulties (Grilo et al. 2001; White and Grilo 2006; Wilfley et al. 2000; Yanovski 1993).

The reasons for the elevations in medical problems are not fully understood, but point to binge eating behavior itself. Some research has found that BED is associated with increased risk of metabolic abnormalities, which may be attributed to the pattern of eating observed in BED. For example, eating large amounts of food in a discrete period of time (BED Diagnostic Criterion A1 in DSM-5) (American Psychiatric Association 2012) is associated with exaggerated insulin secretion, increased fasting glucose levels, decreased glucose tolerance, and elevated serum lipids (Jenkins et al. 1992; Taylor et al. 1999). Eating rapidly (Criterion B1) is associated with elevated serum lipids, higher waist–hip circumference ratio, and fatty liver in obese individuals (Kral et al. 2001). Irregular meal patterns, which are frequently observed in BED (Masheb and Grilo 2006; Masheb et al. 2011) and are described more below, are associated with the metabolic syndrome in the general population (Sierra-Johnson et al. 2008).

Epidemiology of obesity and BED

Lifetime rates of BED have been estimated at 2.8 per cent using DSM-IV-TR criteria (Hudson et al. 2007). The prevalence of BED is higher among obese adults (estimates range from 8 per cent to 28 per cent) (Hudson et al. 2007) and is much higher in most clinical settings, especially obesity-specific treatment facilities and clinics (Johnson et al. 2001; Wilfley et al. 2003). Estimated rates of significant problems with binge eating (although perhaps not meeting the full diagnostic threshold specified in DSM) are much higher, with binge eating reported in as many as 46 per cent of patients in weight control clinics (Marcus et al. 1985).

When looking at the demographic profiles of obese people with BED and obese people who do not binge eat, several differences emerge. On average, BED adults tend to be younger than NBO adults (Kolotkin et al. 2004). This difference may be especially pronounced among obese people presenting for treatment. Among obese treatment-seekers, women are about 1.5 times more likely to have BED than men, and this disparity is found in non-treatment seeking populations as well (Spitzer et al. 1992). Therefore, the gender difference in BED is much less pronounced than it is in anorexia nervosa or bulimia nervosa, wherein women are far more likely to carry these diagnoses than men. Interestingly, while women are more likely to have BED than men, rates of obesity are approximately equivalent in samples of men and women (Ogden et al. 2007). There are larger disparities in rates of obesity in different ethnic groups. Obesity is less prevalent in samples of non-Hispanic, white individuals than in ethnic minority populations such as Hispanic samples, and non-Hispanic, black samples (Flegal et al. 2010). Many published reports of obese people with BED do not have large enough samples of ethnic minority groups to assess for ethnic differences. Of the few studies that have assessed for ethnic differences in rates of BED, several studies have demonstrated equal prevalence rates among black and white obese adults (Smith et al. 1998; Striegel-Moore and Franko 2003). When considering sub-threshold binge eating, however, evidence suggests greater prevalence among non-white groups (Marques et al. 2011). BED is more prevalent among Latino/as than other ethnic/racial groups (Alegria et al. 2007) and is strongly associated with obesity in this ethnic group (Alegria et al. 2007; Marques et al. 2011).

Identification and diagnosis

As the clinical case demonstrates, physicians may not identify people with BED as having the disorder (Crow et al. 2004; Mond et al. 2010). This is unfortunate, since BED is associated with increased health service utilization (Johnson et al. 2001). Moreover, as described above, people with BED are also more likely to suffer from various medical complications. Whereas patients’ primary care physicians may focus on their weight and inform them that weight loss is a health priority, the chaotic and out-of-control nature of the eating itself is unlikely to be addressed. Binge eating poses a significant obstacle to weight loss efforts and, when this issue is ignored, efforts to diet are unlikely to be successful. Critically, people suffering from BED may not realize that treatment is available, and their physicians may not provide adequate referrals.

Psychological functioning in BED

We turn now to discuss psychological functioning in obese people suffering with BED. Most notably, in comparison to obese people who do not binge eat, adults with BED tend to exhibit higher levels of eating disorder-specific pathology in addition to more non-eating-related psychopathology. Compared to their NBO counterparts, adults with BED are more concerned about their weight and shape, and more preoccupied with their eating (Grilo and White 2011; Marcus et al. 1988). This pattern is also found in obese treatment-seeking children and adolescents (Decaluwé et al. 2003). Adults with BED report a greater discrepancy between their current and ideal body size than NBO (Striegel-Moore et al. 1998). There is also a significant subset of BED adults who overvalue their shape and weight, meaning that shape and weight are important aspects by which they evaluate their self-worth. As observed in bulimia nervosa and anorexia nervosa, when overvaluation is present, patients will value their body shape and weight even more than other central aspects of their life, such as career or school, family, and relationships. If their weight and shape are not where they would like them to be, they feel as though they are a “bad person”, or, like Jamie, they may feel as though something is wrong with them and that they are “defective”. Although not a formal diagnostic criterion in BED, this overvaluation of shape and weight is present among many patients, and has prognostic value in treatment. The subgroup of BED adults with overvaluation of body shape and weight has high levels of eating disorder pathology, including bouts of disinhibited eating, unhealthy forms of dietary restraint (i.e., overly and unrealistically restrictive), and binge eating itself (Grilo et al. 2008). Compared to NBO groups and BED groups with lower levels of overvaluation of shape/weight, this high overvaluation subgroup also exhibits higher levels of depressive symptomatology (Grilo et al. 2010).

On average, adults with BED report higher depression, lower quality of life, and lower self-esteem than NBO adults (de Zwaan et al. 2002; Isnard et al. 2003). Much like Jamie, they may feel depressed about their eating, shape, and repeated failed attempts to lose weight. In general, patients with BED tend to be more concerned with rejection and feeling unworthy as compared to NBO (Nauta et al. 2000). Additionally, binge eating obese adults have higher rates of Axis I comorbid psychopathology than NBO (Fontenelle et al. 2003). In particular, they are more likely to suffer from major depression, and, to a lesser extent, anxiety disorders (Fowler and Bulik 1997). In terms of Axis II diagnoses, some evidence suggests that people with BED have significantly higher rates of all personality disorder diagnoses, particularly borderline personality disorder and avoidant personality disorder (Telch and Stice 1998; Yanovski et al. 1993).

Eating patterns

In addition to psychological comorbidity, BED and NBO differ in other important ways that are relevant for clinical interventions. Evidence suggests that BED and NBO adults differ in their eating patterns. Several studies have shown that BED adults consume more calories per day than NBO adults (Engel et al. 2009; Raymond et al. 2003) and this difference is driven primarily by the high number of calories that are consumed on days when people with BED binge eat as compared to non-binge days. On days when people with BED binge, they eat significantly more fat (as opposed to carbohydrates or protein) than they do on non-binge days and compared to NBO adults (Raymond et al. 2003). Binge eating itself is more likely to occur during the midday or evening meal, and many binge episodes occur in restaurants (Allison and Timmerman 2007). Compared to NBO, people with BED eat more snacks, engage in more frequent nibbling or picking episodes, are more likely to eat two of the same meal (e.g., will eat two entire dinners on a single day), and have more nocturnal eating episodes (i.e., when they go to bed and then get up out of bed to eat) (Masheb et al. 2011). Furthermore, the number of binge episode...