Tag: Eating Disorders

What is Emotional Eating?

Published on by Andrew Marshall1 Comment

Introduction

Emotional eating, also known as stress eating and emotional overeating, is defined as the “propensity to eat in response to positive and negative emotions”. While the term often refers to eating as a means of coping with negative emotions, it also includes eating for positive emotions, such as eating foods when celebrating an event or eating to enhance an already good mood. In these situations, emotions are still driving the eating but not in a negative way.

Background

Emotional eating includes eating in response to any emotion, whether that be positive or negative. Most frequently, people refer to emotional eating as “eating to cope with negative emotions.” In these situations, emotional eating can be considered a form of disordered eating, which is defined as “an increase in food intake in response to negative emotions” and can be considered a maladaptive strategy. More specifically, emotional eating in order to relieve negative emotions would qualify as a form of emotion-focused coping, which attempts to minimise, regulate, and prevent emotional distress.

One study found that emotional eating sometimes does not reduce emotional distress, but instead it enhances emotional distress by sparking feelings of intense guilt after an emotional eating session. Those who eat as a coping strategy are at an especially high risk of developing binge-eating disorder, and those with eating disorders are at a higher risk to engage in emotional eating as a means to cope. In a clinical setting, emotional eating can be assessed by the Dutch Eating Behaviour Questionnaire, which contains a scale for restrained, emotional, and external eating. Other questionnaires, such as the Palatable Eating Motives Scale, can determine reasons why a person eats tasty foods when they are not hungry; sub-scales include eating for reward enhancement, coping, social, and conformity.

Characteristics

Emotional eating usually occurs when one is attempting to satisfy his or her hedonic drive, or the drive to eat palatable food to obtain pleasure in the absence of an energy deficit but can also occur when one is seeking food as a reward, eating for social reasons (such as eating at a party), or eating to conform (which involves eating because friends or family wants the individual to). When one is engaging in emotional eating, they are usually seeking out palatable foods (such as sweets) rather than just food in general. In some cases, emotional eating can lead to something called “mindless eating” during which the individual is eating without being mindful of what or how much they are consuming; this can occur during both positive and negative settings.

Emotional hunger does not originate from the stomach, such as with a rumbling or growling stomach, but tends to start when a person thinks about a craving or wants something specific to eat. Emotional responses are also different. Giving in to a craving or eating because of stress can cause feelings of regret, shame, or guilt, and these responses tend to be associated with emotional hunger. On the other hand, satisfying a physical hunger is giving the body the nutrients or calories it needs to function and is not associated with negative feelings.

Major Theories behind Eating to Cope

Current research suggests that certain individual factors may increase one’s likelihood of using emotional eating as a coping strategy. The inadequate affect regulation theory posits that individuals engage in emotional eating because they believe overeating alleviates negative feelings. Escape theory builds upon inadequate affect regulation theory by suggesting that people not only overeat to cope with negative emotions, but they find that overeating diverts their attention away from a stimulus that is threatening self-esteem to focus on a pleasurable stimulus like food. Restraint theory suggests that overeating as a result of negative emotions occurs among individuals who already restrain their eating. While these individuals typically limit what they eat, when they are faced with negative emotions they cope by engaging in emotional eating. Restraint theory supports the idea that individuals with other eating disorders are more likely to engage in emotional eating. Together these three theories suggest that an individual’s aversion to negative emotions, particularly negative feelings that arise in response to a threat to the ego or intense self-awareness, increase the propensity for the individual to utilise emotional eating as a means of coping with this aversion.

The biological stress response may also contribute to the development of emotional eating tendencies. In a crisis, corticotropin-releasing hormone (CRH) is secreted by the hypothalamus, suppressing appetite and triggering the release of glucocorticoids from the adrenal gland. These steroid hormones increase appetite and, unlike CRH, remain in the bloodstream for a prolonged period of time, often resulting in hyperphagia. Those who experience this biologically instigated increase in appetite during times of stress are therefore primed to rely on emotional eating as a coping mechanism.

Contributing Factors

Negative Affect

Overall, high levels of the negative affect trait are related to emotional eating. Negative affectivity is a personality trait involving negative emotions and poor self-concept. Negative emotions experienced within negative affect include anger, guilt, and nervousness. It has been found that certain negative affect regulation scales predicted emotional eating. An inability to articulate and identify one’s emotions made the individual feel inadequate at regulating negative affect and thus more likely to engage in emotional eating as a means for coping with those negative emotions. Further scientific studies regarding the relationship between negative affect and eating find that, after experiencing a stressful event, food consumption is associated with reduced feelings of negative affect (i.e. feeling less bad) for those enduring high levels of chronic stress. This relationship between eating and feeling better suggests a self-reinforcing cyclical pattern between high levels of chronic stress and consumption of highly palatable foods as a coping mechanism. Contrarily, a study conducted by Spoor et al. found that negative affect is not significantly related to emotional eating, but the two are indirectly associated through emotion-focused coping and avoidance-distraction behaviours. While the scientific results differed somewhat, they both suggest that negative affect does play a role in emotional eating but it may be accounted for by other variables.

Childhood Development

For some people, emotional eating is a learned behaviour. During childhood, their parents give them treats to help them deal with a tough day or situation, or as a reward for something good. Over time, the child who reaches for a cookie after getting a bad grade on a test may become an adult who grabs a box of cookies after a rough day at work. In an example such as this, the roots of emotional eating are deep, which can make breaking the habit extremely challenging. In some cases, individuals may eat in order to conform; for example, individuals may be told “you have to finish your plate” and the individual may eat past the point in which they feel satisfied.

Related Disorders

Emotional eating as a means to cope may be a precursor to developing eating disorders such as binge eating or bulimia nervosa. The relationship between emotional eating and other disorders is largely due to the fact that emotional eating and these disorders share key characteristics. More specifically, they are both related to emotion focused coping, maladaptive coping strategies, and a strong aversion to negative feelings and stimuli. It is important to note that the causal direction has not been definitively established, meaning that while emotional eating is considered a precursor to these eating disorders, it also may be the consequence of these disorders. The latter hypothesis that emotional eating happens in response to another eating disorder is supported by research that has shown emotional eating to be more common among individuals already suffering from bulimia nervosa.

Biological and Environmental Factors

Stress affects food preferences. Numerous studies – granted, many of them in animals – have shown that physical or emotional distress increases the intake of food high in fat, sugar, or both, even in the absence of caloric deficits. Once ingested, fat- and sugar-filled foods seem to have a feedback effect that damps stress-related responses and emotions, as these foods trigger dopamine and opioid releases, which protect against the negative consequences of stress. These foods really are “comfort” foods in that they seem to counteract stress, but rat studies demonstrate that intermittent access to and consumption of these highly palatable foods creates symptoms that resemble opioid withdrawal, suggesting that high-fat and high-sugar foods can become neurologically addictive. A few examples from the American diet would include: hamburgers, pizza, French fries, sausages and savoury pasties. The most common food preferences are in decreasing order from: sweet energy-dense food, non-sweet energy-dense food then, fruits and vegetables. This may contribute to people’s stress-induced craving for those foods.

The stress response is a highly-individualised reaction and personal differences in physiological reactivity may also contribute to the development of emotional eating habits. Women are more likely than men to resort to eating as a coping mechanism for stress, as are obese individuals and those with histories of dietary restraint. In one study, women were exposed to an hour-long social stressor task or a neutral control condition. The women were exposed to each condition on different days. After the tasks, the women were invited to a buffet with both healthy and unhealthy snacks. Those who had high chronic stress levels and a low cortisol reactivity to the acute stress task consumed significantly more calories from chocolate cake than women with low chronic stress levels after both control and stress conditions. High cortisol levels, in combination with high insulin levels, may be responsible for stress-induced eating, as research shows high cortisol reactivity is associated with hyperphagia, an abnormally increased appetite for food, during stress. Furthermore, since glucocorticoids trigger hunger and specifically increase one’s appetite for high-fat and high-sugar foods, those whose adrenal glands naturally secrete larger quantities of glucocorticoids in response to a stressor are more inclined toward hyperphagia. Additionally, those whose bodies require more time to clear the bloodstream of excess glucocorticoids are similarly predisposed.

These biological factors can interact with environmental elements to further trigger hyperphagia. Frequent intermittent stressors trigger repeated, sporadic releases of glucocorticoids in intervals too short to allow for a complete return to baseline levels, leading to sustained and elevated levels of appetite. Therefore, those whose lifestyles or careers entail frequent intermittent stressors over prolonged periods of time thus have greater biological incentive to develop patterns of emotional eating, which puts them at risk for long-term adverse health consequences such as weight gain or cardiovascular disease.

Macht (2008) described a five-way model to explain the reasoning behind stressful eating:

  1. Emotional control of food choice;
  2. Emotional suppression of food intake;
  3. Impairment of cognitive eating controls;
  4. Eating to regulate emotions; and
  5. Emotion-congruent modulation of eating.

These break down into subgroups of: Coping, reward enhancement, social and conformity motive. Thus, providing an individual with are stronger understanding of personal emotional eating.

Positive Affect

Geliebter and Aversa (2003) conducted a study comparing individuals of three weight groups: underweight, normal weight and overweight. Both positive and negative emotions were evaluated. When individuals were experiencing positive emotional states or situations, the underweight group reporting eating more than the other two groups. As an explanation, the typical nature of underweight individuals is to eat less and during times of stress to eat even less. However, when positive emotional states or situations arise, individuals are more likely to indulge themselves with food.

Impact

Emotional eating may qualify as avoidant coping and/or emotion-focused coping. As coping methods that fall under these broad categories focus on temporary reprieve rather than practical resolution of stressors, they can initiate a vicious cycle of maladaptive behaviour reinforced by fleeting relief from stress. Additionally, in the presence of high insulin levels characteristic of the recovery phase of the stress-response, glucocorticoids trigger the creation of an enzyme that stores away the nutrients circulating in the bloodstream after an episode of emotional eating as visceral fat, or fat located in the abdominal area. Therefore, those who struggle with emotional eating are at greater risk for abdominal obesity, which is in turn linked to a greater risk for metabolic and cardiovascular disease.

Treatment

There are numerous ways in which individuals can reduce emotional distress without engaging in emotional eating as a means to cope. The most salient choice is to minimise maladaptive coping strategies and to maximise adaptive strategies. A study conducted by Corstorphine et al. in 2007 investigated the relationship between distress tolerance and disordered eating. These researchers specifically focused on how different coping strategies impact distress tolerance and disordered eating. They found that individuals who engage in disordered eating often employ emotional avoidance strategies. If an individual is faced with strong negative emotions, they may choose to avoid the situation by distracting themselves through overeating. Discouraging emotional avoidance is thus an important facet to emotional eating treatment. The most obvious way to limit emotional avoidance is to confront the issue through techniques like problem solving. Corstorphine et al. showed that individuals who engaged in problem solving strategies enhance one’s ability to tolerate emotional distress. Since emotional distress is correlated to emotional eating, the ability to better manage one’s negative affect should allow an individual to cope with a situation without resorting to overeating.

One way to combat emotional eating is to employ mindfulness techniques. For example, approaching cravings with a non-judgemental inquisitiveness can help differentiate between hunger and emotionally-driven cravings. An individual may ask his or herself if the craving developed rapidly, as emotional eating tends to be triggered spontaneously. An individual may also take the time to note his or her bodily sensations, such as hunger pangs, and coinciding emotions, like guilt or shame, in order to make conscious decisions to avoid emotional eating.

Emotional eating can also be improved by evaluating physical facets like hormone balance. Female hormones, in particular, can alter cravings and even self-perception of one’s body. Additionally, emotional eating can be exacerbated by social pressure to be thin. The focus on thinness and dieting in our culture can make young girls, especially, vulnerable to falling into food restriction and subsequent emotional eating behaviour.

Emotional eating disorder predisposes individuals to more serious eating disorders and physiological complications. Therefore, combatting disordered eating before such progression takes place has become the focus of many clinical psychologists.

Stress Fasting

In a lesser percentage of individuals, emotional eating may conversely consist of reduced food intake, or stress fasting. This is believed to result from the fight-or-flight response. In some individuals, depression and other psychological disorders can also lead to emotional fasting or starvation.

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What is the Body Attitudes Test?

Published on by Andrew Marshall1 Comment

Introduction

The Body Attitudes Test (BAT) was developed by Probst et al. in 1995. It was designed for the assessment of multiple eating disorders in women.

The BAT measures an individual’s subjective body experience and attitudes towards one’s own body. It is a questionnaire composed of twenty items which yields four different factors that evaluate the internal view of the patient’s own body.

Refer to Body Attitudes Questionnaire.

Purpose

The BAT is used to evaluate self-reported outlooks women with eating disorders have pre-, during, and post-treatment. It has been proven to highlight the psychological changes experienced throughout the rehabilitation process and is a useful way to gauge adherence and success of treatment.

This test also has the ability to differentiated between clinical and non-clinical subjects and between anorexics and bulimics. Studies have shown that patients suffering from restrictive anorexia have lower BAT scores, whereas patients with bulimia nervosa score higher.

Brief History

Michel Probst and colleagues began creating the BAT in 1984 and eventually published this questionnaire in 1995, with the goal of finding a new tool to evaluate how women suffering from eating disorders view their own body. The BAT was originally written in Dutch and then translated to many languages. This test was administered widely to both patients and control subjects, including women already diagnosed with eating disorders, women participating in Weight Watchers, and healthy women with no eating disorder diagnosis. To ensure the validity of this test, Probst and colleagues compared the results of the BAT to other tools already in use to evaluate women with eating disorders. These other evaluations include the Body Shape Questionnaire (BSQ), the Eating Disorder Inventory (EDI), and the Eating Attitudes Test (EAT).

Test

The BAT is a self-reported questionnaire consisting of 20 questions. Patients are asked to score each statement 0-5, 0 meaning they do not relate to the statement at all, and 5 meaning the statement frequently describes their sentiment. The following are examples of questions asked in the assessment:

  • I feel displeased when comparing my body to others.
  • I do not recognise my body as my own.
  • My body is too wide.
  • I am pleased with my body shape.
  • I feel the need to lose weight.
  • I see my breasts as too big.
  • I feel the need to conceal my body in looser clothing.
  • I avoid my reflection because it upsets me.
  • I do not struggle with relaxing.
  • I feel like every aspect of my body is broad.
  • My body negatively weighs on me.
  • There is a dissonance between my body and I.
  • At times, I feel like my body is swollen.
  • I feel threatened by my physical appearance.
  • I take great pride in my body size.
  • I feel like I look pregnant.
  • I always feel very tense.
  • I tend to be jealous of other people’s looks.
  • Aspects of my physical appearance scare me.
  • I often scrutinise my own reflection.

The answers to these questions are then analysed and provide information regarding four factors that evaluate the patient’s subjective view on their body:

  • Negative appreciation of body size.
  • Lack of familiarity with one’s own body.
  • General body dissatisfaction.
  • Rest factor.

What is the Body Attitudes Questionnaire?

Published on by Andrew Marshall1 Comment

Introduction

The Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) is a 44 item self-report questionnaire divided into six subscales that measures a woman’s attitude towards their own body.

The BAQ is used in the assessment of eating disorders. It was devised by D.I. Ben-Tovim and M.K. Walker in 1991.

Refer to Body Attitudes Test.

Sub-Scales

The six subscales measured by the BAQ are:

  1. Overall fatness.
  2. Self disparagement.
  3. Strength.
  4. Salience of weight.
  5. Feelings of attractiveness.
  6. Consciousness of lower body fat.

Foreign-Language Versions

Portuguese Version

The BAQ was the first body attitudes scale to be translated into Portuguese. The validity of the Portuguese language version was proven in a test conducted on a cohort of Brazilian women who speak Portuguese as their native language. The test-retest reliability was 0.57 and 0.85 after a one-month interval. The test was conducted by Scagliusi et al.

Japanese Version

The BAQ was translated into Japanese and tested on 68 males and 139 females in Japan and 68 Japanese males living in Australia (Kagawa et al.) The scores were assessed against 72 Australian men using the English-language version as well as scores from previous female Australian participants. There was a significant difference between the Japanese and Australian groups (p,0.05). The BAQ was deemed adequate for use in both Japanese males and females.

What is an Intensive Outpatient Programme?

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Introduction

An intensive outpatient programme (IOP) is a kind of treatment service and support programme used primarily to treat eating disorders, bipolar disorder (including mania; and for Bipolar I and Bipolar II), unipolar depression, self harm and chemical dependency that does not rely on detoxification.

Refer to Partial Hospitalisation.

Background

IOP operates on a small scale and does not require the intensive residential or partial day services typically offered by the larger, more comprehensive treatment facilities.

The typical IOP programme offers group therapy and generally facilitates 6-30 hours a week of programming for addiction treatment. IOP allows the individual to be able to participate in their daily affairs, such as work, and then participate in treatment at an appropriate facility in the morning or at the end of the day. With an IOP, classes, sessions, meetings, and workshops are scheduled throughout the day, and individuals are expected to adhere to the strict structure of the program. Online IOP has shown to be effective, as well.

The typical IOP programme encourages active participation in 12-step programmes in addition to IOP participation. IOP can be more effective than individual therapy for chemical dependency.

IOP is also used by some HMOs as transitional treatment for patients just released from treatment in a psychiatric ward.

What is the Body Attitudes Questionnaire?

Published on by Andrew Marshall2 Comments

Introduction

The Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) is a 44 item self-report questionnaire divided into six subscales that measures a woman’s attitude towards their own body.

The BAQ is used in the assessment of eating disorders. It was devised by D.I. Ben-Tovim and M.K. Walker in 1991.

Refer to the Body Attitudes Test.

Sub-Scales

The six subscales measured by the BAQ are:

  • Overall fatness.
  • Self disparagement.
  • Strength.
  • Salience of weight.
  • Feelings of attractiveness.
  • Consciousness of lower body fat.
  • Foreign-language versions.

Portuguese Version

The BAQ was the first body attitudes scale to be translated into Portuguese. The validity of the Portuguese language version was proven in a test conducted on a cohort of Brazilian women who speak Portuguese as their native language. The test-retest reliability was 0.57 and 0.85 after a one-month interval. The test was conducted by Scagliusi et al.

Japanese Version

The BAQ was translated into Japanese and tested on 68 males and 139 females in Japan and 68 Japanese males living in Australia (Kagawa et al.) The scores were assessed against 72 Australian men using the English-language version as well as scores from previous female Australian participants. There was a significant difference between the Japanese and Australian groups (p,0.05). The BAQ was deemed adequate for use in both Japanese males and females.

References

Ben-Tovim, D.I. & Walker, M.K. (1991) The development of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ), a new measure of women’s attitudes towards their own bodies. Psychological Medicine. 21(3), pp.775-784. doi:10.1017/S0033291700022406.

Kagawa, M., Uchida, H., Uenishi, K., Binns, C.W. & Hills, A.P. (2007) Applicability of the Ben-Tovim Walker Body Attitudes Questionnaire (BAQ) and the Attention to Body Shape scale (ABS) in Japanese males and females (PDF). Eating Behaviors. 8(3), pp.2772-284. doi:10.1016/j.eatbeh.2006.11.002.

Scagliusi, F.B., Polacow, V.O., Cordas, T.A., Coelho, D., Alvarenga, M., Philippi, S.T. & Lancha Jr, A.H. (2005) Psychometric testing and applications of the Body Attitudes Questionnaire translated into Portuguese. Perceptual and Motor Skills. 101(1), pp.25-41. doi:10.2466/PMS.101.5.25-41.

What is the Body Attitudes Test?

Published on by Andrew Marshall2 Comments

Introduction

The Body Attitudes Test (BAT) was developed by Probst and colleagues in 1995.

Refer to Body Attitudes Questionnaire.

Background

It was designed for the assessment of eating disorders in women. The BAT measures an individual’s subjective body experience and attitudes towards one’s own body it differentiates between clinical and non-clinical subjects and between anorexics and bulimics. It is composed of twenty items which yield four factors:

  1. Negative appreciation of body size.
  2. Lack of familiarity with one’s own body.
  3. General body dissatisfaction.
  4. A rest factor.

Reference

Probst, M. Van Coppenolle, H. & Vandereycken, W. (1997) Further experience with the Body Attitude Test. Eating and Weight Disorders. 2(2), pp.100104. doi:10.1007/bf03339956.

What is an Other Specified Feeding or Eating Disorder?

Published on by Andrew Marshall1 Comment

Introduction

Other specified feeding or eating disorder (OSFED) is a DSM-5 category that, along with unspecified feeding or eating disorder (UFED), replaces the category formerly called eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR.

It captures feeding disorders and eating disorders of clinical severity that do not meet diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), pica, or rumination disorder.

OSFED includes five examples:

  1. Atypical anorexia nervosa.
  2. Atypical bulimia nervosa of low frequency and/or limited duration.
  3. Binge eating disorder of low frequency and/or limited duration.
  4. Purging disorder.
  5. Night eating syndrome (NES).

Brief History

In 1980, DSM-III was the first DSM to include a category for eating disorders that could not be classified in the categories of AN, BN, or pica. This category was called Atypical Eating Disorder. Atypical Eating Disorder was described in one sentence in the DSM-III and received very little attention in the literature, as it was perceived to be uncommon compared to the other defined eating disorders. In DSM-III-R, published in 1987, the Atypical Eating Disorder category became known as Eating Disorder Not Otherwise Specified (EDNOS). DSM-III-R included examples of individuals who would meet criteria for EDNOS, in part to acknowledge the increasingly recognized heterogeneity of individuals within the diagnostic category.

In 1994, DSM-IV was published and expanded EDNOS to include six clinical presentations. These presentations included individuals who:

  • Met criteria for AN, but continued to menstruate;
  • Met criteria for AN, but still had weight in the normal range despite significant weight loss;
  • Met criteria for BN but did not meet frequency criterion for binge eating or purging;
  • Engaged in inappropriate compensatory behaviour after eating small amounts of food; or
  • Repeatedly chewed or spit out food, or who binged on food but did not subsequently purge.

A disadvantage of DSM-IV’s broad EDNOS category was that people with very different symptoms were still classified as having the same diagnosis, making it difficult to access care specific to the disorder and conduct research on the diversity of pathology within EDNOS. Furthermore, EDNOS was perceived as less severe than AN or BN, despite findings that individuals diagnosed with EDNOS share similarities with full-threshold AN or BN in the degree of eating pathology, general psychopathology, and physical health. This perception prevented people in need from seeking help or insurance companies from covering treatment costs. DSM-5, published in 2013, sought to address these issues by adding new diagnoses and revising existing criteria.

Epidemiology

Few studies to date have examined OSFED prevalence. The largest community study is by Stice (2013), who examined 496 adolescent females who completed annual diagnostic interviews over 8 years. Lifetime prevalence by age 20 for OSFED overall was 11.5%. 2.8% had atypical AN, 4.4% had subthreshold BN, 3.6% had subthreshold BED, and 3.4% had purging disorder. Peak age of onset for OSFED was 18-20 years. NES was not assessed in this study, but estimates from other studies suggest that it presents in 1% of the general population.

A few studies have compared the prevalence of EDNOS and OSFED and found that though the prevalence of atypical eating disorders decreased with the new classification system, the prevalence still remains high. For example, in a population of 215 young patients presenting for ED treatment, the diagnosis of EDNOS to OSFED decreased from 62.3% to 32.6%. In another study of 240 females in the US with a lifetime history of an eating disorder, the prevalence changed from 67.9% EDNOS to 53.3% OSFED. Although the prevalence appears to reduce when using the categorisations of EDNOS vs. OSFED, a high proportion of cases still receive diagnoses of atypical eating disorders, which creates difficulties in communication, treatment planning, and basic research.

Classification

The five OSFED examples that can be considered eating disorders include atypical AN, BN (of low frequency and/or limited duration), BED (of low frequency and/or limited duration), purging disorder, and NES. Of note, OSFED is not limited to these five examples, and can include individuals with heterogeneous eating disorder presentations (i.e. OSFED-other). Another term, UFED, is used to describe individuals for whom full diagnostic criteria are not met but the reason remains unspecified or the clinician does not have adequate information to make a more definitive diagnosis.

Atypical Anorexia NervosaIn atypical AN, individuals meet all of the criteria for AN, with the exception of the weight criterion: the individual’s weight remains within or above the normal range, despite significant weight loss.
Atypical Bulimia NervosaIn this sub-threshold version of BN, individuals meet all criteria for BN, with the exception of the frequency criterion: binge eating and inappropriate compensatory behaviours occur, on average, less than once a week and/or for fewer than 3 months.
Binge Eating Disorder of Low Frequency and/or Limited DurationIn this sub-threshold version of BED, individuals must meet all criteria for BED, with the exception of the frequency criterion: binge eating occurs, on average, less than once a week and/or for fewer than 3 months.
Purging DisorderIn purging disorder, purging behaviour aimed to influence weight or shape is present, but in the absence of binge eating.
Night Eating SyndromeIn NES, individuals have recurrent episodes of eating at night, such as eating after awakening from sleep or excess calorie intake after the evening meal. This eating behaviour is not culturally acceptable by group norms, such as the occasional late-night munchies after a gathering. NES includes an awareness and recall of the eating, is not better explained by external influences such as changes in the individual’s sleep-wake cycle, and causes significant distress and/or impairment of functioning.

Though not defined specifically in DSM-5, research criteria for this diagnosis proposed adding the following criteria (1) the consumption of at least 25% of daily caloric intake after the evening meal and/or (2) evening awakenings with ingestions at least twice per week.

Treatment

Few studies guide the treatment of individuals with OSFED. However, cognitive behavioural therapy (CBT), which focuses on the interplay between thoughts, feelings, and behaviours, has been shown to be the leading evidence-based treatment for the eating disorders of BN and BED. For OSFED, a particular cognitive behavioural treatment can be used called CBT-Enhanced (CBT-E), which was designed to treat all forms of eating disorders. This method focuses not only what is thought to be the central cognitive disturbance in eating disorders (i.e. over-evaluation of eating, shape, and weight), but also on modifying the mechanisms that sustain eating disorder psychopathology, such as perfectionism, core low self-esteem, mood intolerance, and interpersonal difficulties. CBT-E showed effectiveness in two studies (total N = 219) and well maintained over 60-week follow-up periods. CBT-E is not specific to individual types of eating disorders but is based on the concept that common mechanisms are involved in the persistence of atypical eating disorders, AN, and BN.

What is an Unspecified Feeding or Eating Disorder?

Published on by Andrew Marshall1 Comment

Introduction

Unspecified feeding or eating disorder (UFED) is a Diagnostic and Statistical Manual of Mental Disorders (DSM-5 category of eating disorders that, along with other specified feeding or eating disorder (OSFED), replaced eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR.

UFED is an eating disorder that does not meet the criteria for: anorexia nervosa, bulimia nervosa, binge eating disorder, or OSFED. Individuals with EDNOS have similar symptoms and behaviours to those with anorexia and bulimia, and can face the same dangerous risks.

Signs and Symptoms

Rather than providing specific diagnostic criteria for EDNOS, the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) listed six non-exhaustive example presentations, including individuals who:

  • Meet all criteria for anorexia nervosa except they have regular menses.
  • Meet all criteria for anorexia nervosa except their weight falls within the normal range.
  • Meet all criteria for bulimia nervosa except they engage in binge eating or purging behaviours less than twice per week or for fewer than three months.
  • Use inappropriate compensatory behaviour (such as purging, excessive exercise, or fasting) after eating small amounts of food while retaining a normal body weight.
  • Repeatedly chew and spit out large amounts of food without swallowing.
  • Meet criteria for “binge eating disorder”: recurrent binge eating and no regular inappropriate compensatory behaviours.

Despite its subclinical status in DSM-IV, available data suggest that EDNOS is no less severe than the officially recognized DSM-IV eating disorders. In a comprehensive meta-analysis of 125 studies, individuals with EDNOS exhibited similar levels of eating pathology and general psychopathology to those with anorexia nervosa and binge eating disorder, and similar levels of physical health problems as those with anorexia nervosa. Although individuals with bulimia nervosa scored significantly higher than those with EDNOS on measures of eating pathology and general psychopathology, those with EDNOS exhibited more physical health problems than those with bulimia nervosa.

Diagnosis

Although no longer in the DSM-5, the three general categories for an EDNOS diagnosis are subthreshold symptoms of anorexia or bulimia, a mixture of both anorexic or bulimic symptoms, and clinically-significant disordered eating behaviours that are not described by anorexia and bulimia. EDNOS is no longer considered a diagnosis in DSM-5. Because some diagnostic criteria were loosened and new diagnoses were introduced in DSM-5, those displaying symptoms of what would previously have been considered EDNOS are now classified under anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder(ARFID), other specified feeding or eating disorder (OSFED), or unspecified feeding or eating disorder (UFED).

Epidemiology

Although EDNOS (formerly called atypical eating disorder) was originally introduced in DSM-III to capture unusual cases, it accounts for up to 60% of cases in eating disorder specialty clinics. EDNOS is an especially prevalent category in populations that have received inadequate research attention such as young children, males, ethnic minorities, and non-Western groups.

Treatment

When treating any eating disorder, including unspecified disorders, it is important to include a registered dietician or nutritionist working with the treatment team. Even though eating disorders are a psychological diagnosis, psychologists are not certified or licensed in dietetics or nutrition, so it is important that psychologists are not practicing outside their bounds of competence. Medical Nutrition Therapy is vital in the treatment and management of eating disorders. The dietician assists the patient by creating a meal plan that is tailored to their individual needs and treatment goals. The dietician will also provide psychoeducation that challenges nutrition misinformation and will ideally create a space where the patient feels comfortable asking questions.

What is Binge Eating Disorder?

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Introduction

Binge eating disorder (BED) is an eating disorder characterised by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviours common to Bulimia Nervosa, OSFED, or the Binge-Purge subtype of Anorexia Nervosa.

BED is a recently described condition, which was required to distinguish binge eating similar to that seen in bulimia nervosa but without characteristic purging. Individuals who are diagnosed with bulimia nervosa and binge eating disorder exhibit similar patterns of compulsive overeating, neurobiological features of dysfunctional cognitive control and food addiction, and biological and environmental risk factors. Some professionals consider BED to be a milder form of bulimia with the two conditions on the same spectrum.

Binge eating is one of the most prevalent eating disorders among adults, though there tends to be less media coverage and research about the disorder in comparison to anorexia nervosa and bulimia nervosa.

Brief History

The disorder was first described in 1959 by psychiatrist and researcher Albert Stunkard as “night eating syndrome” (NES). The term “binge eating” was coined to describe the same bingeing-type eating behaviour but without the exclusive nocturnal component.

There is generally less research on binge eating disorder in comparison to anorexia nervosa and bulimia nervosa.

Signs and Symptoms

Binge eating is the core symptom of BED; however, not everyone who binge eats has BED. An individual may occasionally binge eat without experiencing many of the negative physical, psychological, or social effects of BED. This may be considered disordered eating rather than a clinical disorder. Precisely defining binge eating can be problematic, however binge eating episodes in BED are generally described as having the following potential features:

  • Eating much faster than normal, perhaps in a short space of time.
  • Eating until feeling uncomfortably full.
  • Eating a large amount when not hungry.
  • Subjective loss of control over how much or what is eaten.
  • Binges may be planned in advance, involving the purchase of special binge foods, and the allocation of specific time for binging, sometimes at night.
  • Eating alone or secretly due to embarrassment over the amount of food consumed.
  • There may be a dazed mental state during the binge.
  • Not being able to remember what was eaten after the binge.
  • Feelings of guilt, shame or disgust following a food binge.

In contrast to bulimia nervosa, binge eating episodes are not regularly followed by activities intended to compensate for the amount of food consumed, such as self-induced vomiting, laxative or enema misuse, or strenuous exercise. BED is characterised more by overeating than dietary restriction. Those with BED often have poor body image and frequently diet, but are unsuccessful due to the severity of their binge eating.

Obesity is common in persons with BED, as is depression, low self-esteem, stress and boredom. Those with BED are also at risk of Non-alcoholic fatty liver disease, menstrual irregularities such as amenorrhea, and gastrointestinal problems such as acid reflux and heartburn.

Causes

As with other eating disorders, binge eating is an “expressive disorder” – a disorder that is an expression of deeper psychological problems. People who have binge eating disorder have been found to have higher weight bias internalisation, which includes low self-esteem, unhealthy eating patterns, and general body dissatisfaction. Binge eating disorder commonly develops as a result or side effect of depression, as it is common for people to turn to comfort foods when they are feeling down.

There was resistance to give binge eating disorder the status of a fully fledged eating disorder because many perceived binge eating disorder to be caused by individual choices. Previous research has focused on the relationship between body image and eating disorders, and concludes that disordered eating might be linked to rigid dieting practices. In the majority of cases of anorexia, extreme and inflexible restriction of dietary intake leads at some point to the development of binge eating, weight regain, bulimia nervosa, or a mixed form of eating disorder not otherwise specified. Binge eating may begin when individuals recover from an adoption of rigid eating habits. When under a strict diet that mimics the effects of starvation, the body may be preparing for a new type of behaviour pattern, one that consumes a large amount of food in a relatively short period of time.

Some studies show that BED aggregates in families and could be genetic. However, very few published studies around the genetics exist.

However, other research suggests that binge eating disorder can also be caused by environmental factors and the impact of traumatic events. One study showed that women with binge eating disorder experienced more adverse life events in the year prior to the onset of the development of the disorder, and that binge eating disorder was positively associated with how frequently negative events occur. Additionally, the research found that individuals who had binge eating disorder were more likely to have experienced physical abuse, perceived risk of physical abuse, stress, and body criticism. Other risk factors may include childhood obesity, critical comments about weight, low self-esteem, depression, and physical or sexual abuse in childhood. A systematic review concluded that bulimia nervosa and binge eating disorder are more impacted by family separations, a loss in their lives and negative parent-child interactions compared to those with anorexia nervosa. A few studies have suggested that there could be a genetic component to binge eating disorder, though other studies have shown more ambiguous results. Studies have shown that binge eating tends to run in families and a twin study by Bulik, Sullivan, and Kendler has shown a, “moderate heritability for binge eating” at 41%. More research must be done before any firm conclusions can be drawn regarding the heritability of binge eating disorder. Studies have also shown that eating disorders such as anorexia and bulimia reduce coping abilities, which makes it more likely for those suffering to turn to binge eating as a coping strategy.

A correlation between dietary restraint and the occurrence of binge eating has been shown in some research. While binge eaters are often believed to be lacking in self-control, the root of such behaviour might instead be linked to rigid dieting practices. The relationship between strict dieting and binge eating is characterised by a vicious circle. Binge eating is more likely to occur after dieting, and vice versa. Several forms of dieting include delay in eating (e.g. not eating during the day), restriction of overall calorie intake (e.g. setting calorie limit to 1,000 calories per day), and avoidance of certain types of food (e.g. “forbidden” food, such as sugar, carbohydrates, etc.). Strict and extreme dieting differs from ordinary dieting. Some evidence suggests the effectiveness of moderate calorie restriction in decreasing binge eating episodes among overweight individuals with binge eating disorder, at least in the short-term.

In the US it is estimated that 3.5% of young women and 30% to 40% of people who seek weight loss treatments, can be clinically diagnosed with binge eating disorder.

Diagnosis

International Classification of Diseases

BED was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1994 simply as a feature of eating disorder. In 2013 it gained formal recognition as a psychiatric condition in the DSM-5.

The 2017 update to the American version of the ICD-10 includes BED under F50.81. ICD-11 may contain a dedicated entry (6B62), defining BED as frequent, recurrent episodes of binge eating (once a week or more over a period of several months) which are not regularly followed by inappropriate compensatory behaviours aimed at preventing weight gain.

Diagnostic and Statistical Manual

Previously considered a topic for further research exploration, binge eating disorder was included in the DSM in 2013. Until 2013, binge eating disorder was categorized as an Eating Disorder Not Otherwise Specified, an umbrella category for eating disorders that don’t fall under the categories for anorexia nervosa or bulimia nervosa. Because it was not a recognised psychiatric disorder in the DSM-IV until 2013, it has been difficult to obtain insurance reimbursement for treatments. The disorder now has its own category under DSM-5, which outlines the signs and symptoms that must be present to classify a person’s behaviour as binge eating disorder. Studies have confirmed the high predictive value of these criteria for diagnosing BED.

According to the World Health Organization’s ICD-11 classification of BED, the severity of the disorder can be classified as mild (1-3 episodes/week), moderate (4-7 episodes/week), severe (8-13 episodes/week) and extreme (>14 episodes/week).

One study claims that the method for diagnosing BED is for a clinician to conduct a structured interview using the DSM-5 criteria or taking the Eating Disorder Examination. The Structured Clinical Interview takes no more than 75 minutes to complete and has a systematic approach which follows the DSM-5 criteria. The Eating Disorder Examination is a semi-structured interview which identifies the frequency of binges and associated eating disorder features.

Treatment

Counselling and certain medication, such as lisdexamfetamine and selective serotonin reuptake inhibitor (SSRIs), may help. Some recommend a multidisciplinary approach in the treatment of the disorder.

Counselling

Cognitive behavioural therapy (CBT) treatment has been demonstrated as a more effective form of treatment for BED than behavioural weight loss programmes. 50% of BED individuals achieve complete remission from binge eating and 68-90% will reduce the amount of binge eating episodes they have. CBT has also been shown to be an effective method to address self-image issues and psychiatric comorbidities (e.g. depression) associated with the disorder. The goal of CBT is to interrupt binge-eating behaviour, learn to create a normal eating schedule, change the perception around weight and shape and develop positive attitudes about one’s body. Although this treatment is successful in eliminating binge eating episodes, it does not lead to losing any weight. Recent reviews have concluded that psychological interventions such as psychotherapy and behavioural interventions are more effective than pharmacological interventions for the treatment of binge eating disorder. A meta-analysis concluded that psychotherapy based on CBT not only significantly improved binge-eating symptomatology but also reduced a client’s BMI significantly at posttreatment and longer than 6 and 12 months after treatment. There is the 12-step Overeaters Anonymous or Food Addicts in Recovery Anonymous. Behavioural weight loss treatment has been proven to be effective as a means to achieve weight loss amongst patients.

Medication

Lisdexamfetamine is a US Food and Drug Administration (FDA)-approved drug that is used for the treatment of moderate to severe binge eating disorder in adults.

Three other classes of medications are also used in the treatment of binge eating disorder: antidepressants, anticonvulsants, and anti-obesity medications. Antidepressant medications of the selective serotonin reuptake inhibitor (SSRI) have been found to effectively reduce episodes of binge eating and reduce weight. Similarly, anticonvulsant medications such as topiramate and zonisamide may be able to effectively suppress appetite. The long-term effectiveness of medication for binge eating disorder is currently unknown. For BED patients with manic episodes, risperidone is recommended. If BED patients have bipolar depression, lamotrigine is appropriate to use.

Trials of antidepressants, anticonvulsants, and anti-obesity medications suggest that these medications are superior to placebo in reducing binge eating. Medications are not considered the treatment of choice because psychotherapeutic approaches, such as CBT, are more effective than medications for binge eating disorder. A meta-analysis concluded that using medications did not reduce binge-eating episodes and BMI posttreatment at 6-12 months. This indicates a potential possibility of relapse after withdrawal from the medications. Medications also do not increase the effectiveness of psychotherapy, though some patients may benefit from anticonvulsant and anti-obesity medications, such as phentermine/topiramate, for weight loss.

Blocking opioid receptors leads to less food intake. Additionally, bupropion and naltrexone used together may cause weight loss. Combining these alongside psychotherapies like CBT may lead to better outcomes for BED.

Surgery

Bariatric surgery has also been proposed as another approach to treat BED and a recent meta-analysis showed that approximately two-thirds of individuals who seek this type of surgery for weight loss purposes have BED. Bariatric surgery recipients who had BED prior to receiving the surgery tend to have poorer weight-loss outcomes and are more likely to continue to exhibit eating behaviours characteristic of BED.

Lifestyle Interventions

Other treatments for BED include lifestyle interventions like weight training, peer support groups, and investigation of hormonal abnormalities.

Prognosis

Individuals suffering from BED often have a lower overall quality of life and commonly experience social difficulties. Early behaviour change is an accurate prediction of remission of symptoms later.

Individuals who have BED commonly have other comorbidities such as major depressive disorder, personality disorder, bipolar disorder, substance abuse, body dysmorphic disorder, kleptomania, irritable bowel syndrome, fibromyalgia, or an anxiety disorder. Individuals may also exhibit varying degrees of panic attacks and a history of attempted suicide.

While people of a healthy weight may overeat occasionally, an ongoing habit of consuming large amounts of food in a short period of time may ultimately lead to weight gain and obesity. Bingeing episodes usually include foods that are high in fat, sugar, and/or salt, but low in vitamins and minerals, as these types of foods tend to trigger the greatest chemical and emotional rewards. The main physical health consequences of this type of eating disorder are brought on by the weight gain resulting from calorie-laden bingeing episodes. Mental and emotional consequences of binge eating disorder include social weight stigma and emotional loss of control. Up to 70% of individuals with BED may also be obese, and therefore obesity-associated morbidities such as high blood pressure and coronary artery disease type 2 diabetes mellitus gastrointestinal issues (e.g. gallbladder disease), high cholesterol levels, musculoskeletal problems and obstructive sleep apnoea may also be present.

Epidemiology

General

The prevalence of BED in the general population is approximately 1-3%, with BED cases usually occurring between the ages of 12.4 and 24.7, but prevalence rates increase until the age of 40. Binge eating disorder is the most common eating disorder in adults.

The limited amount of research that has been done on BED shows that rates of binge eating disorder are fairly comparable among men and women. The lifetime prevalence of binge eating disorder has been observed in studies to be 2.0% for men and 3.5% for women, higher than that of the commonly recognised eating disorders anorexia nervosa and bulimia nervosa. However another systematic literature review found the prevalence average to be about 2.3% in women and about 0.3% in men. Lifetime prevalence rates for BED in women can range anywhere from 1.5 to 6 times higher than in men. One literature review found that point prevalence rates for BED vary from 0.1% to 24.1% depending on the sample. This same review also found that the 12-month prevalence rates vary between 0.1% to 8.8%.

Recent studies found that eating disorders which included anorexia nervosa, bulimia nervosa and binge-eating disorder are common among sexual and gender minority populations, including gay, lesbian, bisexual and transgender people. This could be due to the minority stress and discrimination this population experiences.

Due to limited and inconsistent information and research on ethnic and racial differences, prevalence rates are hard to determine for BED. Rates of binge eating disorder have been found to be similar among black women, white women, and white men, while some studies have shown that binge eating disorder is more common among black women than among white women. However, majority of the research done around BED is focused on White women. One literature review found information citing no difference between BED prevalence among Hispanic, African American, and White women while other information found that BED prevalence was highest among Hispanics followed by Black individuals and finally White people.

Worldwide Prevalence

Eating disorders have usually been considered something that was specific to Western countries. However, the prevalence of eating disorders is increasing in other non-Western countries. Though the research on binge eating disorders tends to be concentrated in North America, the disorder occurs across cultures. In the USA, BED is present in 0.8% of male adults and 1.6% of female adults in a given year.

The prevalence of BED is lower in Nordic countries compared to Europe in a study that included Finland, Sweden, Norway, and Iceland. The point prevalence ranged from 0.4 to 1.5% and the lifetime prevalence ranged from 0.7 to 5.8% for BED in women.

In a study that included Argentina, Brazil, Chile, Colombia, Mexico, and Venezuela, the point prevalence for BED was 3.53%. Therefore, this particular study found that the prevalence for BED is higher in these Latin American countries compared to Western countries.

The prevalence of BED in Europe ranges from <1 to 4%.

Co-Morbidities

BED is co-morbid with diabetes, hypertension, previous stroke, and heart disease in some individuals.

In people who have obsessive-compulsive disorder or bipolar I or II disorders, BED lifetime prevalence was found to be higher.

Additionally, 30 to 40% of individuals seeking treatment for weight-loss can be diagnosed with binge eating disorder.

Underreporting in Men

Eating disorders are oftentimes underreported in men. Underreporting could be a result of measurement bias due to how eating disorders are defined. The current definition for eating disorders focuses on thinness. However, eating disorders in men tend to centre on muscularity and would therefore warrant a need for a different measurement definition. Further research should focus on including more men in samples since previous research has focused primarily on women.

What is an Eating Disorder Inventory?

Published on by Andrew Marshall2 Comments

Introduction

The Eating Disorder Inventory (EDI) is a self-report questionnaire used to assess the presence of eating disorders:

  • Anorexia nervosa both restricting and binge-eating/purging type;
  • Bulimia nervosa; and
  • Eating disorder not otherwise specified including binge eating disorder.

The original questionnaire consisted of 64 questions, divided into eight subscales. It was created in 1984 by David M. Garner and others. There have been two subsequent revisions by Garner:

  • The Eating Disorder Inventory-2 (EDI-2); and
  • The Eating Disorder Inventory-3 (EDI-3).

Diagnostic Use

The Eating Disorder Inventory is a diagnostic tool designed for use in a clinical setting to assess the presence of an eating disorder. It is generally used in conjunction with other psychological tests such as the Beck Depression Inventory. Depression has been shown to yield higher scores on the EDI-3.

Eating Disorder Inventory

The Eating Disorder Inventory (EDI) comprises 64 questions, divided into eight subscales. Each question is on a 6-point scale (ranging from “always” to “never”), rated 0-3. The score for each sub-scale is then summed. The 8 subscale scores on the EDI are:

  • Drive for thinness: an excessive concern with dieting, preoccupation with weight, and fear of weight gain.
  • Bulimia: episodes of binge eating and purging.
  • Body dissatisfaction: not being satisfied with one’s physical appearance.
  • Ineffectiveness: assesses feelings of inadequacy, insecurity, worthlessness and having no control over their lives.
  • Perfectionism: not being satisfied with anything less than perfect.
  • Interpersonal distrust: reluctance to form close relationships.
  • Interoceptive awareness: “measures the ability of an individual to discriminate between sensations and feelings, and between the sensations of hunger and satiety”.
  • Maturity fears: The fear of facing the demands of adult life.

Eating Disorder Inventory-2

The first revision of the EDI was in 1991. The 1991 version, Eating Disorder Inventory-2 (EDI-2) is used for both males and females over age 12. The EDI-2 retains the original format of the EDI with the inclusion of 27 new items divided into three additional subscales:

  • Asceticism: reflects the avoidance of sexual relationships.
  • Impulse regulation: shows the ability to regulate impulsive behaviour, especially the binge behaviour.
  • Social insecurity: estimates social fears and insecurity.

Eating Disorder Inventory-3

The latest revision to the Eating Disorder Inventory was released in 2004. It contains the original items of the first version as well as EDI-2, and was also enhanced to reflect more modern theories related to the diagnosis of eating disorders. It was designed for use with females ages 13-53 years, and can be administered in 20 minutes. It contains 91 items divided into twelve subscales rated on a 0-4 point scoring system. Three items on the EDI-3 are specific to eating disorders, and 9 are general psychological scales that are relevant to eating disorders. The inventory yields six composite scores: eating disorder risk, ineffectiveness, interpersonal problems, affective problems, overcontrol, and general psychological maladjustment.

Eating Disorder Symptom Checklist

The Eating Disorder Symptom Checklist is a separate self-report form used to measure the frequency of symptoms (i.e., binge eating; the use of laxatives, diet pills; exercise patterns). The information provided by the checklist aids in determining whether patients meets the diagnostic criteria as set forth in the Diagnostic and Statistical Manual of Mental Disorders IV-TR for an eating disorder.

Eating Disorder Referral Form

The Eating Disorder Referral Form is an abbreviated form of the EDI-3 for use in non-clinical settings such as the allied health professions. It contains 25 questions from the EDI-3 that are specific to eating disorder risk. It also includes questions specific to the behavioural patterns of someone with or at risk of developing an eating disorder. The referral form utilizes indexes based on body mass index in identifying at risk patients.