Binge eating disorder should be included in DSM-IV: a reply to Fairburn et al.'s "the classification of recurrent overeating: the binge eating disorder proposal"

Extensive recent research supports a proposal that a new eating disorder, binge eating disorder (BED), be included in DSM-IV. BED criteria define a relatively pure group of individuals who are distressed by recurrent binge eating who do not exhibit the compensatory features of bulimia nervosa. This large number of patients currently can only be diagnosed as eating disorder not otherwise specified (EDNOS). Recognizing this new disorder will help stimulate research and clinical programs for these patients. Fairburn et al.'s critique of BED fails to acknowledge the large body of knowledge that indicates that BED represents a distinct and definable subgroup of eating disordered patients and that the diagnosis provides useful information about psychopathology, prognosis, and outcome (Fairburn, Welch, & Hay [in press]. The classification of recurrent overeating: The "binge eating disorder" proposal. International Journal of Eating Disorders.) Against any reasonable standard for adding a new diagnosis to DSM-IV, BED meets the test.

Assessment of binge eating in obese patients

Obese patients entering a weight control program were classified as binge eaters if they reported uncontrolled consumption of what others would regard as an unusually large amount of food at least once a week for the previous month. Binge eaters differed significantly from nonbingers across a broad range of eating and weight-related characteristics assessed using a self-report version of the Eating Disorder Examination. Attitudinal differences were marked. The results provided no support for the view that obese binge eaters have a pattern of general "addictiveness" to psychoactive substances or other activities.

Striatal regulation of morphine-induced hyperphagia: an anatomical mapping study

Both systemic and intracranial administration of morphine can result in spontaneous feeding in non-deprived rats. The present investigation was conducted to examine the involvement of the striatum in this phenomenon. Morphine sulfate (0, 0.5, 1.0, 5.0, 10.0, and 20.0 micrograms/0.5 microliters) was microinjected into five discrete striatal subregions in non-deprived rats: the nucleus accumbens, the ventromedial striatum, the ventrolateral striatum, the anterior dorsal striatum, and the posterior dorsal striatum. Feeding, drinking, locomotion, rearing, and food intake were measured over 4 h after infusion. Results indicate that the striatum is a heterogeneous structure with regard to the regulation of opiate-induced feeding behavior and locomotor activity. Morphine infusion into anteroventromedial regions including the nucleus accumbens resulted in a marked hyperphagia that was generally delayed in onset; much smaller increases or no change in feeding occurred after administration into more dorsal, lateral and posterior areas. It is hypothesized that there may exist within the striatum an anatomical gradient that is most sensitive to opiate-induced feeding within the anteroventromedial sector. Since this area has extensive connections with other brain sites sensitive to opiate-induced feeding, it may be a critical part of an opiatergic feeding system within the brain. In addition, a possible role for the anteroventromedial striatum in compulsive feeding and bulimia is discussed.

Bulimia nervosa in Hong Kong Chinese patients

In contrast to the West, bulimic disorders are rarer than anorexia nervosa in Hong Kong. Four female normal-weight bulimic patients with mostly typical clinical features and conspicuous morbidity are reported. The case histories support the hypothesis that binge-eating is used to regulate unpleasant effect.

Personal and parental alcohol abuse, and victimization in obese binge eaters and nonbingeing obese

Current obesity research has begun to emphasize the importance of pretreatment assessment and more individually tailored treatment protocols. Obese binge eaters have been identified as a subgroup of the obese who do not respond well to standard behavioral treatment programs. We were interested in identifying variables that are important to consider when assessing and treating obese binge eaters. The present study assessed the prevalence of personal alcohol abuse, parental alcohol abuse, and victimization in 62 males and 274 females seeking treatment for obesity. Obese binge eaters (OBE) had significantly greater rates of personal alcohol abuse, parental alcohol abuse, and victimization than the nonbingeing obese (NBO) in our sample. Further studies of the OBE population are recommended.

Endogenous corticotropin-releasing factor modulates feeding induced by neuropeptide Y or a tail-pinch stressor

Previous work has characterized an anorexic action for endogenous, central nervous system corticotropin-releasing factor (CRF). Central injection of CRF decreases food intake induced pharmacologically by various appetite stimulants and a CRF antagonist attenuates restraint stress anorexia. Also, stressful physiological stimuli that are relevant to ingestive regulation, such as glucoprivation and protein nutrient deficiency, activate CRF systems. The present experiments examined the effects of exogenously administered CRF and a CRF antagonist, alpha-helical CRF(9-41), on spontaneous feeding induced by neuropeptide Y (NPY) and by a tail-pinch stressor. Pretreatment with a low dose of the CRF antagonist (1 microgram ICV) enhanced the hyperphagia induced by NPY while reducing the latency to begin feeding and increasing the duration of eating during tail pinch. Higher doses of alpha-hel CRF (5 and 25 micrograms ICV) exhibited diminishing or opposite effects. In contrast, CRF pretreatment (0.02, 0.1, and 0.5 microgram ICV) blocked the acquisition of tail-pinch feeding. Hence, while CRF administration impairs intake in these and other feeding paradigms, alpha-hel CRF actually facilitated dose dependently the intensity of the feeding response to NPY and tail pinch. These results suggest that endogenous CRF systems may play a role in modulating excessive feeding under conditions of evoked appetite and that brain CRF systems regulate feeding when excessive intake threatens to compromise the performance of other noningestive behaviors.

[Consumer behaviors in obesity due to overeating. The usefulness and limits of diet therapy]

Appropriate dietary prescription has still a useful place in a weight reducing program, but no such program must be prescribed before careful evaluation of the risk for psychological derangement that may be the consequence. A rational interdisciplinary approach is essential. The importance of correcting a sedentary life style must not be overlooked.

Binge eating in overweight women

Data on the prevalence and characteristics of binge eating in a series of 64 obese women participating in a controlled weight-reduction program are presented. Twenty-two (34.4%) reported recurrent binge eating episodes defined as overeating plus loss of control as assessed by patients' self-report and confirmed by a clinical interview. Six of those indicated that they engaged in either self-induced vomiting or laxative use to control their weight, but only two met full criteria for current bulimia nervosa according to DSM-III-R. A detailed description of the binge eating behavior revealed similarities to the eating pattern described in patients with bulimia nervosa: obese binge eaters tended to overeat in the evening, when they were alone and at home. Compared with their non-binge eating counterparts, binge eaters were significantly younger when they presented for treatment. The prevalence of childhood obesity was higher, and they were significantly younger when they first started on a diet than the non-binge eaters. Binge eaters reported more psychological problems such as body image distortion, and there was a slight tendency for binge eaters to exhibit more depressive symptomatology at baseline. No association between binge eating and weight at baseline, or weight loss during therapy or at follow-up could be found. Fluvoxamine (100 mg) did not seem to be of specific benefit in this subgroup of the obese with regard to weight loss.

Triazolam-induced nocturnal bingeing with amnesia

A combination of behavioural and cognitive adverse effects is illustrated in this case report of a recurrent triazolam-induced eating disorder. The co-occurrence of bingeing, irritability and anterograde amnesia is suggestive of a drug-induced Kleine-Levin Syndrome.

Kleine-Levin syndrome: a case report

Kleine-Levin Syndrome is an unusual sleep disorder occurring predominantly, but not exclusively, in late adolescent males. A case is described which illustrates some of the difficulties in diagnosis and management.

Emotional arousal and overeating in restrained eaters

We tested the effects of 3 mood inductions (neutral, positive, and negative) on food intake in 91 women of varying degrees of dietary restraint. Mood induction was accomplished by exposure to 1 of 3 film segments: a travelogue (neutral affect), a comedy film (positive affect), and a horror film (negative affect). In subjects exposed to the neutral film, food intake decreased with increasing levels of dietary restraint. Among subjects who viewed either the comedy film or the horror film, however, food intake increased with increasing restraint. Although the horror film appeared to be more disinhibiting than the comedy film, this effect may have resulted from a difference in the intensity of the emotions induced rather than from their valence. These results suggest that emotional arousal, regardless of valence, may trigger overeating among restrained eaters.

Treatment response in obese binge eaters: preliminary results using a very low calorie diet (VLCD) and behavior therapy

The present study compared the treatment response of male and female obese binge eaters and nonbinge eaters attending a university-based weight reduction program employing a very low calorie diet (VLCD) and concurrent behavior therapy. Twenty-nine percent of female patients (n = 19) and 22% of male patients (n = 6) were characterized as binge eaters based on their scores on the Binge Eating Scale. No significant differences were found between binge and nonbinge groups on measures of weight loss, adherence to the diet, or drop-out rate, although a trend towards greater attrition in the binge group (32%) relative to the nonbinge group (17%) was noted. However, binge eaters had significantly higher pretreatment levels of trait anxiety, state anxiety, and depression as well as higher within treatment levels of anxiety and depression despite significant reductions in depression over the course of treatment. Further examination revealed a binge status X sex interaction effect on state anxiety. Binge-eating females had significantly higher anxiety levels pretreatment and throughout the 10 weeks of the study. No differences between binge and nonbinge males on levels of anxiety were found. These preliminary results tentatively suggest that a VLCD in conjunction with behavior therapy may be an effective method of weight loss for this segment of the obese population, but that elevated levels of anxiety persist in female patients. Future studies must address the long-term maintenance of weight loss in this population as well as other treatment strategies.

Feeding patterns in bulimia nervosa

We characterized the naturalistic feeding patterns of 54 women with bulimia nervosa and 11 matched controls over a continuous 24-hr period in a feeding laboratory. Overall, bulimic women consumed more calories in 24 hr (4446 +/- 584 kcal) than did controls (1845 +/- 649 kcal). Bulimic women consumed a wide range of caloric intake, with 44% overeating and 19% undereating in comparison to the range of controls. In addition, bulimics showed a disruption of circadian feeding patterns. For overeating bulimic women, the majority of meals were of normal size and frequency. Increased caloric intake in the group of overeating bulimic women was mainly due to the fact that 37% of their meals were greater than 1000 calories. Large meals occurred predominantly during the afternoon and evening and consisted primarily of dessert and snack foods. Importantly, the percentage of fat, but not carbohydrates, consumed increased as meal size, and 24-hr caloric intake increased. This study is the first to describe the naturalistic feeding characteristics of a large number of bulimics by direct observation. These findings are consistent with previous self-reports and extend and replicate previous laboratory studies. We think that laboratory studies are a reasonable replica of naturalistic feeding and should facilitate further investigation of the psychological and physiological correlates of feeding behavior in eating disorders.

Compulsive overeating

Compulsive overeating is a behavior used in an attempt to numb or nurture feelings that are threatening to the person. Emotional states are soothed by use of food. Treatment is designed to respond to internal, biologic causes of hunger and satiety while simultaneously allowing feelings to surface and be dealt with. Work on the inner child enables the person to identify and deal with unmet needs and correct distortions from childhood. The secondary gain realized from the extra weight is examined, and direct means of dealing with these needs explored. The focus of recovery is on learning to nurture the self, physically and emotionally.

[Kleine-Levin syndrome]

The Kleine-Levin syndrome is generally considered to be a benign functional disorder of hypothalamic structures. Its onset is usually in adolescence. The most characteristic symptoms are periodic hypersomnia, excessive eating, hypersexuality, irritability and apathy. Associated features are depressive and schizophrenic symptoms. A biological relationship between the Kleine-Levin syndrome and endogenous psychoses is discussed.

Binge eating as escape from self-awareness

This article proposes that binge eating is motivated by a desire to escape from self-awareness. Binge eaters suffer from high standards and expectations, especially an acute sensitivity to the difficult (perceived) demands of others. When they fall short of these standards, they develop an aversive pattern of high self-awareness, characterized by unflattering views of self and concern over how they are perceived by others. These aversive self-perceptions are accompanied by emotional distress, which often includes anxiety and depression. To escape from this unpleasant state, binge eaters attempt the cognitive response of narrowing attention to the immediate stimulus environment and avoiding broadly meaningful thought. This narrowing of attention disengages normal inhibitions against eating and fosters an uncritical acceptance of irrational beliefs and thoughts. The escape model is capable of integrating much of the available evidence about binge eating.

High-fat diets stimulate transient hyperphagia whereas wet diets stimulate prolonged hyperphagia in Fischer rats

The effectiveness of several different kinds of diets in stimulating hyperphagia in Fischer strain rats was compared. Of three different high-fat diets examined, only one stimulated significant hyperphagia and stimulated weight gain; this diet was high in both fat and carbohydrate. However, this hyperphagia and increased weight gain was transient, lasting less than four weeks. A high-sucrose diet stimulated energy intake for only one week. In contrast, adding water to a high-starch diet or adding saccharin to a wet diet stimulated energy intake and weight gain for at least ten weeks. Once water or saccharin were removed from these diets, hyperphagia subsided or even turned into hypophagia, until body weights approached control levels. The degree of hyperphagia during the first week did not correlate with subsequent hyperphagia or weight gain. These results suggest that wet diets act by different mechanisms than do dry high-fat and high-sucrose diets.

[Kleine-Levin syndrome]

The Kleine-Levin syndrome is generally considered to be a benign functional disorder of hypothalamic structures. Its onset is usually in adolescence. The most characteristic symptoms are periodic hypersomnia, excessive eating, hypersexuality, irritability and apathy. Associated features are depressive and schizophrenic symptoms. A biological relationship between the Klein-Levin syndrome and endogenous psychoses is discussed.

A behavioral taxonomy of obese female participants in a weight-loss program

To create a behavioral classification of obesity, 2-wk baseline food diaries were obtained from 236 obese women entering weight-loss programs. Subjects monitored food intake along with the social, environmental, and emotional context in which each meal occurred. Variables representing situation-specific eating behaviors were statistically extracted from greater than 11,000 eating episodes. Hierarchical cluster analysis identified five distinct groups of subjects on the basis of similarity of eating patterns. The five groups were (1) moderately healthy eating habits, (2) chronic food restrictors, (3) alternating diet-binge eaters, (4) emotional overeaters, (5) unrestricted meal overeaters. The five groups differed on questionnaire measures of emotional adjustment and eating behavior but did not differ on dropout rates, amount of weight lost, or exercise compliance. The chronic food restrictors had significantly less lean body mass, lower resting metabolic rates, and higher waist-to-hip ratios than did the unrestricted meal overeaters.

Dysfunctional family systems: relationships to disordered eating behaviors among university women

Clinicians have speculated that the appearance and maintainance of eating-disordered behavior may be attributed to certain familial characteristics which predispose vulnerable individuals to the development of these behaviors. However, few empirical studies exist to substantiate these speculations. This study compared the responses of 190 female university students on three self-report instruments: the Disordered Eating and Weight Control Instrument (DEWCI), the Eating Disorders Instrument (EDI), and the Family Adaptability and Cohesion Evaluation Scale (FACES III) to identify potential relationships between eating-disordered behavior and family types. Subjects were classified, on the basis of their scores on the FACES III, into one of three family types: balanced, midrange, or extreme. A one-way analysis of variance with main effect for family type was applied to the eating-behavior subscales. A Turkey multiple comparison test was applied to the significant main effects. Women classified in the extreme family type scored significantly higher (p less than .05) on several measures of eating-disordered behavior. A Distance From Center (DFC) linear score also was computed and correlated with the eating-disordered subscales. All but 4 of the 18 measures correlated significantly (p less than .05). These findings support speculation, particularly that of family theorists, that eating-disordered behavior may be a symptom response and/or coping strategy for women in dysfunctional families.

Hyperendorphinemia in obesity is not related to the affective state

In seventy-two patients affected by hyperphagic obesity and forty age-matched, normal weight volunteers we performed a psychological assessment, through various mental tests, and evaluated the beta-endorphin (B-Ep), ACTH and cortisol circulating levels, in basal condition and following an overnight short dexamethasone suppression test (DST). The hormones were measured by radioimmunoassay either directly in the serum (cortisol) and the plasma (ACTH), or after affinity gel column chromatography (B-Ep). In obese subjects B-Ep levels in basal conditions were four times greater than in normal weight controls and showed significantly less reduction after DST. ACTH and cortisol levels, in contrast, were in the normal range and were suppressed following dexamethasone as was also true in the control group. Psychological evaluation on M.M.P.I. (Minnesota Multiphasic Personality Inventory) revealed a trend toward hypochondria, depression, hysterias, psychoasthenia and schizophrenia. However, no significant correlation has been found between M.M.P.I. clinical scale scores and circulating levels of B-Ep and cortisol either in basal conditions or after DST. In conclusion, these data do not support the hypothesis that abnormalities of the hypothalamus-pituitary-adrenal axis in hyperphagic obesity are related to affective disorders.