Binge eating disorder: clinical features and treatment of a new diagnosis

This review will describe the diagnostic criteria for the recently proposed diagnosis of binge eating disorder and provide an overview of its prevalence, clinical characteristics, and treatment approaches. Studies indicate that binge eaters represent a substantial proportion (18-46%) of the obese in weight control programs. Normal-weight patients with bulimia nervosa, obese binge eaters, and obese nonbinge eaters appear to represent three distinct populations, with obese nonbinge eaters showing the least psychological disturbance and patients with bulimia nervosa exhibiting the most. Preliminary findings indicate that obese binge eaters may be more likely than nonbinge eaters to drop out of treatment when treated by conventional weight loss programs, although weight losses achieved by binge eaters and nonbinge eaters who finish treatment do not differ significantly. Treatment programs that focus on the disturbed eating behavior appear to be effective to some degree in reducing binge eating frequency and related pathology, but patients tend to relapse after completion of treatment. Operationalized criteria such as the proposed DSM-IV criteria for binge eating disorder could facilitate coordinated research on binge eaters who do not meet criteria for bulimia nervosa.

Cognitive treatments for eating disorders

Cognitive-behavioral therapy (CBT) is applicable to all eating disorders but has been most intensively studied in the treatment of bulimia nervosa (BN). CBT is designed to alter abnormal attitudes about body shape and weight, replace dysfunctional dieting with normal eating habits, and develop coping skills for resisting binge eating and purging. CBT is effective in reducing all core features of BN and shows good maintenance of therapeutic improvement. Although superior to therapy with antidepressant drugs, CBT has not been shown to be consistently superior to alternative psychological treatments. Different hypotheses about CBT's mechanisms of action are discussed.

[Kleine-Levin syndrome]

The Kleine-Levin syndrome is a rare and probably underdiagnosed syndrome. It is characterized by periodic attacks of the triad: hypersomnia, vegative disturbances such as hyperphagia and hypersexuality, psychopathological changes in the level of consciousness and control of emotions. Boys and young men in the age group 10-20 years are most commonly affected. Spontaneous remission with a tendency to remission is observed and the disease "burns out" after a prolonged period of years. The etiology and pathogenesis are unknown. Theories have been propounded suggesting dysfunction of the hypothalamus. No pathognomonic findings have been observed in the early phase of sleep during the daylight hours. Central stimulating drugs have been reported to have some effect on the hypersomnia. The diagnosis is based on the clinical picture. Frequently, a long period can elapse before the diagnosis is established and some cases are never diagnosed. The literature is reviewed and is illustrated by two case reports.

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.

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.

Conditioning processes and cue exposure in the modification of excessive eating

Excessive eating is one of the principal characteristics of bulimia. Eating more than intended is also a prominent feature both of obese people who are trying to lose weight and normal weight women who are attempting to restrict their food intake. Overeating tends to be triggered by a specific set of cues, which commonly involve either mood disturbances or exposure to "forbidden" food, but may include other environmental cues. It is argued that conditioning processes are relevant both to the establishment of meal patterns in normal subjects and in the maintenance of excessive eating. Treatment procedures have typically followed the general approach of "Self Management" which emphasises reducing exposure to the cues associated with eating. An alternative approach derives from the idea that the association between eating responses (or urges to eat) and external cues may be learned, and therefore should in principle be ameanable to extinction through systematic unreinforced exposure. In this article the possible mechanisms of cue-induced overeating are discussed and the potential utility of cue exposure techniques for the management of excessive eating evaluated.

The use of hypnosis in establishing a holding environment to facilitate affect tolerance and integration in impulsive patients

This paper is concerned with the use of hypnosis in establishing a facilitating and holding environment in the treatment of impulsive behavior across a range of diagnoses. The reason for this cross-diagnostic viewpoint is to underscore the common sources of such action and the needs to be met in its treatment. Illustrations from work with two patients are presented: One was a hypomanic and bulimic woman who was successful in her profession; the other was an underemployed and sometimes unemployed schizophrenic man. Both were inclined to self-defeating impulsive action-bulimia in the woman, assault in the man.

Bulimia: primary care approach and intervention

Bulimia is a serious and increasingly prevalent eating disorder involving both the ingestion of large quantities of food and the subsequent purging of the ingested calories. Nurse practitioners can effectively intervene in cases of bulimia because of their ability to assess the bulimic's potential medical problems and provide the health education and counseling necessary to stop the dangerous binge/purge cycle. Clues aiding in the diagnosis of bulimia include frequent weight fluctuations, enlargement of the patient's parotid glands, dental erosion, menstrual irregularity, electrolyte imbalance and depression. Interventions should address the patient's medical problems, disrupt the binge/purge cycle, help the patient to establish normal eating patterns, raise the bulimic's self-esteem and help resolve underlying depression.

Eating disorders: diagnosis and management by the internist

Anorexia nervosa and bulimia are two of the four eating disorders that appear to be increasingly prevalent. Each has its own diagnostic criteria and medical hazards, though certain features are shared. It is important for internists to be aware of these disorders, since their management is best accomplished by a team consisting of an internist, a psychotherapist, and a nutritionist. The internist's key role in anorexia nervosa is in encouraging and coordinating treatment; in bulimia it is in making a diagnosis. In both, the internist is called upon to recognize and treat medical complications and to collaborate in the management and follow-up of these patients.

The need for psychiatric-dental liaison in the treatment of bulimia

During dental examinations 38% of 66 outpatients with bulimia were found to have evidence of significant enamel erosion, and chronicity of vomiting was significantly associated with erosion. Liaison with colleagues in dentistry is necessary when working with bulimic patients.

The treatment of anorexia nervosa

The author reviews recent advances in the treatment of anorexia nervosa. In addition to the usual areas of weight restoration and psychotherapy, he focuses on difficult issues such as how to engage the patient in treatment, the evaluation of the patient, treatment goals, outpatient treatment, and treatment of bulimic and chronic patients. Where expert opinions differ, the author attempts to give a balanced view while acknowledging the relative lack of research data.

Subjective evaluation of treatment methods by patients treated for bulimia

The authors present data obtained from telephone interviews with 35 patients who were considered recovered 12 to 15 months following treatment for bulimia. Subjects were asked to rate treatment approaches and treatment components as to their helpfulness. The results show that activities within the domain of dietitians can play an important part in the treatment of bulimia.

Bulimia nervosa: treatment and short-term outcome

Fifty-six bulimia nervosa patients were treated by means of a behavioural approach and followed for at least one year after completion or dropping out of treatment. Outcome was encouraging in about half of the patients and several psychiatric indicators, such as duration of illness and response to treatment, were identified. The significance of the findings and unresolved methodological issues are discussed.

Bulimia and parotid enlargement--case report and treatment

Bulimia is a behavioral eating disorder affecting young adult women. Parotid enlargement may occur as a result, although the cause of this swelling is as yet unknown. These changes can be irreversible, unresponsive to resumption of normal dietary habits. The physical unattractiveness of this complication can adversely affect the patient's wellbeing, demanding more active treatment. Treatment of this parotid enlargement has not previously been dealt with definitively. A case study is presented wherein such an individual was treated with bilateral superficial parotidectomy with good results, both emotionally and physically. As the incidence of this disorder continues to increase dramatically, the surgeon may gain a place in the treatment of bulimia.