Kelly C Berg and Carol B Peterson

End Binge Eating Disorder

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Case study

I am a nurse manager at a local hospital, am married, and have two adolescent boys, ages 13 and 17. I'm seeking treatment for binge eating (BE), which occurs several times a week. As a child I would sneak food from my family's kitchen and hoard it in my bedroom. I would come home from school and binge in my room by myself. In typical episodes I would eat half a bag of brown sugar or a box of cookies. My BE has fluctuated in severity since childhood, with the worst periods occurring during college, my late twenties, and currently. My binge episodes usually occur in the evenings after dinner, when alone in the kitchen cleaning up and watching Tv. In a typical BE episode I eat two pints of ice cream or 30 to 50 snack crackers and experience a sense of loss of control, particularly a feeling of being unable to resist eating the food that I know is in the kitchen. I have struggled with being overweight since adolescence and have made multiple attempts at weight loss, including structured programs and diet pills. My BMI has fluctuated from 24 to 36.5, based on measured height and weight, and it was 31.2 at the time of the evaluation.

Donna, a 52-year-old African American female

The accurate assessment and diagnosis of binge eating disorder (BED) can have enormous benefits for the process and outcome of treatment as well as clinical rapport (Peterson 2005). Assessment is the foundation of ongoing treatment because it can be used to inform diagnosis, identify treatment priorities, and measure treatment progress and outcome. Moreover, when psychosocial assessments are conducted effectively, the assessment process can facilitate trust, enhance clinical rapport, and reduce the likelihood of attrition (Peterson 2005). The use of structured assessment tools in conjunction with clinical interviews can improve the reliability of self-reported data and ensure that the assessment is comprehensive.

Overall, research suggests that BED is not restricted to any specific subgroup of clients based on age, gender, race, or ethnicity (e.g., Swanson et al. 2011), is not necessarily associated with weight status (e.g., Hudson et al. 2007), and is often overlooked in clinical and medical settings (e.g., Hudson et al. 2007; Swanson et al. 2011). As such, it is recommended that clinicians assess BED symptoms in all patients, regardless of their clinical or demographic characteristics. Accordingly, this chapter aims to provide guidelines for the assessment and diagnosis of BED that can be used by clinicians regardless of whether they specialize in eating or weight disorders. Topics include the following: a) diagnostic criteria for BED; b) tips for how to integrate BED assessment into a clinical interview; c) special considerations when assessing BED; and d) descriptions of several structured assessment tools that are widely used and potentially helpful in the assessment of BED symptoms.

Section I: Diagnostic criteria for binge eating disorder

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association 2000) did not formally recognize BED as a full-threshold eating disorder (ED). Rather, the DSM-IV-TR included BED as an example of eating disorder not otherwise specified (EDNOS), a diagnosis that was assigned to individuals with clinically significant ED symptoms that did not meet criteria for either anorexia nervosa (AN) or bulimia nervosa (BN) (American Psychiatric Association 2000). However, the following specific criteria for BED were included in Appendix B of the DSM-IV-TR: a) BE, defined by the consumption of an unusually large amount of food accompanied by a sense of loss of control over eating; (b) the BE occurs, on average, twice per week for six months; c) the BE is accompanied by at least three associated features (e.g., eating more rapidly than normal, eating until uncomfortably full, eating large amounts of food when not physically hungry, eating alone because of feeling embarrassed about how much one is eating, and feeling disgusted, depressed, or guilty after eating); d) significant distress regarding BE; and e) the absence of AN and BN. It is important to note, however, that the purpose of these criteria was to encourage research on the validity of the syndrome rather than to diagnose patients in clinical practice.

With the publication of the fifth edition of the DSM (American Psychiatric Association 2012), several changes to the BED criteria must be noted. First, and most importantly, DSM-5 will include BED as a formal ED diagnosis. The DSM-5 criteria for BED are largely unchanged from those included in the appendix of DSM-IV-TR, including the fact that diagnoses of AN and BN "trump" BED. The exception is that the frequency and duration of BE will be reduced to once per week for three months. In sum, the diagnosis of BED requires the assessment of the following variables: a) presence and frequency of BE; b) the associated features of BE; and c) distress associated with BE. It is also generally useful to assess weight status and the presence and frequency of compensatory behaviors, as this information enables AN, BN, and potential medical co-morbidities to be ruled out.

Section II: Assessing binge eating disorder in a clinical interview

During clinical interviews, clinicians are required to obtain a comprehensive assessment while developing and maintaining rapport with the client, two goals that may, at times, be at odds with one another (Peterson 2005). Clinicians working in specialized ED clinics may choose to conduct a comprehensive assessment of BE with all patients; however, in general outpatient clinics, a comprehensive assessment of BED may not be necessary or feasible. Therefore, clinicians in general practice may choose to screen for BE and then follow up with a more comprehensive assessment if necessary.

Screening for binge eating

Questions used to screen for BED can be easily integrated into a clinical interview. Clinicians may find it easiest to transition slowly from relatively benign questions about eating patterns to more pointed questions about BE. Given that many clinicians already ask questions about sleep and eating patterns to assess patients' self-care as well as to assess potential mood disorder symptoms, these questions can provide a natural segue into a screen for BED. For example, general questions such as "What is your general eating pattern?" and "Do you ever skip meals?" can introduce the topic of eating behaviors without causing initial discomfort. At this point, clinicians can gently transition into more specific questions regarding BE, such as "Have you ever felt a sense of loss of control over your eating?" If a patient endorses BE or loss of control eating, additional probing is required to determine whether the patient meets DSM-5 criteria for BED. Although asking directly about the presence of BE may yield an affirmative response, the term "binge eating" is often defined differently by clients and patients than it is by clinicians (Beglin and Fairburn 1992). Asking about episodes of "overeating" or times when the patient believed that they had eaten too much at one time may yield more accurate responses with less confusion (Fairburn et al. 2008).

Making differential diagnoses

If BED is suspected, additional probing can be used to confirm a BED diagnosis. of primary importance to differential diagnosis for BED is the presence and frequency of BE. As described above, BE is characterized by eating an unusually large amount of food and simultaneously experiencing a sense of loss of control over one's eating. Determining whether an amount of food is unusually large can be problematic. For example, most people would agree that a gallon of ice cream would be an unusually large amount of ice cream to eat in one sitting (Arikian et al. 2012). However, what if a patient reported eating cake and ice cream? Whether this amount of food would be considered unusually large would likely depend on a variety of factors such as the kind of cake, how many slices of cake, the size of the slices, how much ice cream, and perhaps the environmental context (e.g., at home on a typical day vs. at a holiday party). To further complicate the assessment of BE, research suggests that patient factors such as gender and BMI may impact whether an amount of food should be considered unusually large (Arikian et al. 2012). When assessing the amount of food consumed during BE episodes, it is generally helpful to elicit at least two specific examples of BE episodes and to obtain extensive detail about the type and quantity of food consumed as well as the context of the episode. In addition, it can be helpful to assess the extent to which these examples are "typical" of other BE episodes (Fairburn et al. 2008).

Loss of control can also be difficult to assess because it is a subjective feeling that may be experienced differently across patients. Although many patients may spontaneously endorse feeling as though their eating is out of their control, clinicians may find that for some patients, they will need to provide specific examples of how loss of control eating might feel. For example, the clinician could ask whether the patient felt that they could have stopped or resisted eating or whether their eating felt driven or compelled (Fairburn et al. 2008). Some patients may deny that their eating feels out of control because they report that their "binges" are planned in advance. However, loss of control eating can still be present in the context of a planned BE episode. Even in the cases of "planned" binges, patients will often indicate that they felt driven or compelled to carry out the binge, which reflects a sense of loss of control over their eating. In this case, the clinician can ask whether the patient felt as though they could have resisted going to the restaurant or if the patient felt as though they had to go, even if they did not really want to go. Additionally, the clinician can ascertain whether the patient could have stopped eating the food once they had started.

Once it has been established that a patient is experiencing BE episodes that are characterized by the consumption of a large amount of food and accompanied by a sense of lack of control, it is necessary to determine the frequency and duration of the episodes, the extent to which the BE episodes are characterized by the associated features of BE (e.g., eating until uncomfortably full), and whether there is significant distress regarding the BE. Additionally, it is important to rule out AN and BN, both of which "trump" a diagnosis of BED. AN can be ruled out by determining the patient's weight status, particularly the extent to which the individual is underweight. The DSM-IV-TR recommended that underweight be defined as less than 85 per cent of expected weight; however, the DSM-5 allows clinicians to exercise more clinical judgment in determining whether a patient is underweight. If a patient does not meet criteria for underweight, a diagnosis of AN can be ruled out. To diagnose BN, BE must be accompanied by the regular use of compensatory behaviors. Therefore, the absence of regular compensatory behaviors (i.e., self-induced vomiting, laxative misuse, diuretic misuse, fasting, or excessive exercise) would rule out BN. Importantly, although weight gain can be associated with regular BE, it also can indicate another medical (e.g., hypothyroidism) or psychiatric (e.g., depression) condition that may require treatment.

Questions about the onset and nature of symptoms as well as referral to a medical specialist can clarify whether weight gain is due to BED or other condition.

Case example

Donna: My eating is just really out of control right now. It feels like every time I eat, I binge - especially at night.

Clinician: It sounds like it feels as though the binge eating has taken over your life.

Donna: That's right, it has.

Clinician: Do you mind if I ask you some specific questions about your binge eating?

Donna: No, go ahead.

Clinician: Okay. First, I'd like you to think of a recent binge episode and describe exactly what you had to eat and how much of it you had.

Donna: Does it matter when the binge happened?

Clinician: If you can think of a more recent episode, perhaps one that occurred in the last month, that might be easier to remember.

Donna: Well, I remember last night's episode. I was cleaning up after dinner and then just started eating the food that I was supposed to be putting away.

Clinician: What types of food were you eating?

Donna: I heated a frozen lasagna, made a salad and French bread. We had just eaten dinner. I wasn't hungry but kept eating the leftovers while cleaning up. I couldn't seem to stop myself.

Clinician: So you had lasagna, salad, and French bread. Did you have anything else to eat?

Donna: We also had dessert. We each had a bowl of ice cream after dinner.

Clinician: Okay, so how much of the lasagna did you have for dinner?

Donna: I had one square.

Clinician: How big was the square? Can you estimate the size?

Donna: It was probably 4" x 4". And then when I was cleaning up, I probably ate another square the same size.

Clinician: What about salad?

Donna: I think I had about a cup of salad. It was a Caesar salad.

Clinician: Did you have any salad when you were cleaning up?

Clinician: And what about the bread?

Donna: I ate a piece of bread at dinner and another one when I was cleaning up. They were slices of regular French bread, about three inches long.

Clinician: And how much ice cream did you have?

Donna: We each had a bowl of ice cream.

Clinician: Do you have any idea how much ice cream was in each bowl?

Probably about 1.5 cups. And then I ate more when I was cleaning up. I ate the rest of the container. It was probably three or four more cups.

And during this episode last night, did your eating feel out of control?

I actually felt sort of resigned. I knew what was going to happen. I knew that I was going to keep eating when I started cleaning up. Did it feel like you had a choice in the matter? Did you feel like you could have resisted eating more when you were cleaning up? Or did you feel like you were driven or compelled to keep eating? No, it didn't feel like a choice. I felt I had to do it. Like with the ice cream, I had to eat it all until the container was empty. So I guess, yeah, I did feel like it was out of my control. That makes sense. And about how much time went by from the time you started eating dinner until you were done cleaning up? About an hour and a half.

You have done a great job describing that episode, especially the details of what you ate and how it felt. I really feel like I have a sense of what that was like for you. Now I'd like you to describe one more episode of binge eating. You can describe a similar episode or, if you're having different types of episodes, you could describe one of those. For example, if you have binge eating episodes at work, or during the day, or outside your home, it would be helpful to hear about those as well.

Section III: Special considerations for the assessment of binge eating disorder

All psychological assessment can be compromised by one or more biases (e.g., minimization, confusion regarding terminology; Schacter 1999). However, the assessment of BE and related symptoms can be especially challenging given the potential for inadvertent or deliberate minimization of symptoms and recall biases. In addition, special considerations may be warranted when assessing and diagnosing BED in children, adolescents, and culturally diverse groups.

Inadvertent or deliberate minimization

Patients with BED may minimize symptoms for a number of reasons. For example, some patients may inadvertently minimize symptoms because they misunderstand abstract constructs (e.g., loss of control) or because they have limited capacity for self-awareness. Confusion can often be avoided by providing concrete information about the symptoms being assessed (e.g., "By binge eating, I mean eating an amount of food that other people may consider unusually large and feeling as though you're unable to control what or how much you're eating";

Donna:

Clinician:

Donna:

Clinician:

Donna:

Clinician:

Donna: Clinician:

First et al. 1995) and by obtaining detailed information whenever possible. In contrast, some patients may deliberately minimize symptom severity because of feelings of shame or an attachment to their BE (e.g., Vitousek et al. 1998). In such cases, accurate self-disclosure may be enhanced by conveying empathy, encouraging collaboration, avoiding criticism, and posing questions or statements in an open-ended format (Miller and Rollnick 2002). Additionally, patients may feel reassured when clinicians convey a matter of fact and accepting attitude towards topics that may be a source of shame (e.g., quantity or type of food consumed during a binge). Non-verbal signals can also affect minimization. For example, lengthy silences, hesitation, or facial cues can imply judgment, lack of expertise, or fear and should be avoided (Miller and Rollnick 2002; Vitousek et al. 1998).

Recall biases

Beyond minimization, information provided during a clinical interview can be influenced by a number of biases. For example, research has demonstrated that people with or without BED tend to underestimate their intake in both daily food records and retrospective recall. In addition, retrospective recall can be impacted by a person's current mood and behavior (Schacter 1999). Finally, research suggests that BE may function to reduce or mitigate negative affect (Smyth et al. 2007) and in the process, lead to symptoms of dissociation or cognitive narrowing (Heatherton and Baumeister 1991). As such, BE may be particularly difficult to recall accurately. To minimize recall biases, clinicians may choose to implement the timeline follow-back procedure (e.g., (Fairburn et al. 2008, Sobell et al. 1979), which orients participants to the past 12 weeks and then asks them to recall the frequency of behaviors during that period. In addition, asking detailed questions can reduce potential overgeneralization (e.g., "Are weekends any different than weekdays?"; Fairburn et al. 2008).

Assessment of binge eating with children and adolescents

Like Donna, other people with BED often report that their BE began in childhood or adolescence and that these episodes often occurred in secret. Indeed, recent epidemiological evidence suggests that BED is more common in children and adolescents than originally thought (e.g., Swanson et al. 2011). Although the symptom presentations of children and adolescents with BED are similar to those of adults with BED, two specific issues unique to the assessment of BE in children and adolescents can make assessment of BE particularly challenging in younger patients.

First, children and adolescents may have a particularly difficult time recalling the type and quantity of food consumed during BE episodes. In addition to using the timeline follow-back procedure and obtaining concrete examples as described above, clinicians may find it useful to provide pictures of food or plastic models of food to help younger clients arrive at more accurate estimates of the quantity and type of food consumed. Relatedly, the clinician's task of determining whether the amount of food consumed was "unusually large" may be especially problematic when assessing children and adolescents because nutritional requirements vary by age, gender, height, and developmental status (Tanofsky-Kraff et al. 2011).

Second, the criteria for BE includes "a sense of lack of control over eating during the episode", which can be difficult to assess among children and adolescents if their eating is largely controlled by their parent(s) or guardian(s). Furthermore, determining whether a child or adolescent has lost control of their eating requires cognitive skills (e.g., abstract reasoning, meta-cognition) that may not be fully developed in younger clients (Bravender et al. 2011). Using age-appropriate metaphors to describe loss of control can enhance comprehension. For example, the child version of the Eating Disorder Examination (see below) describes loss of control as a car rolling down a hill with no brakes. When assessing symptoms of BE in children and adolescents, consideration may also be given to parental reports and behavioral indicators (e.g., hoarding food, sneaking food).

Assessment of binge eating with diverse client groups

Assessing symptoms of BED in diverse client groups can also pose unique challenges because the cognitive and behavioral symptoms of BED need to be determined in the context of culturally normative experiences. Some types of overeating, for example, may be culturally normative and, as such, would not be indicative of BED (Becker 2011). Additionally, some culturally diverse patients and clients may misunderstand assessment questions that include concepts that are foreign in their culture (e.g., loss of control; Becker 2011). Assessments that overlook cultural differences in symptom presentations or language could lead to BED being under-diagnosed, over-diagnosed, or misdiagnosed. Asking open-ended questions, soliciting concrete examples, and clarifying abstract concepts can help ensure accurate assessment.

Section IV: structured assessment tools

When used in conjunction with unstructured clinical interviews, structured assessments can improve the reliability and scope of self-reported data (Anderson et al. 2004; Peterson 2005). In addition, structured assessment instruments can offer objective data regarding a patient's treatment progress and outcome, provide the opportunity to aggregate patient data for program evaluation, and improve communication between clinicians and across treatment centers.

Structured Interviews

Widely used in research, the Eating Disorder Examination (EDE) (Fairburn et al. 2008) is a clinician-administered interview that assesses cognitive and behavioral symptoms of EDs and is considered the most accurate and comprehensive ED

assessment (Grilo 2005; Wilson 1993). The EDE can be used as either a dimensional assessment of symptom severity or as a diagnostic tool. Four subscale scores (i.e., Restraint, Eating Concern, Shape Concern, and Weight Concern) can be derived from the EDE and used to compare scores to normative data from community samples. The EDE also measures behavioral symptoms of EDs during the past three months, including the frequency of BE and compensatory behaviors. Psychometric data support the reliability and validity of the EDE (Berg et al. 2012) and research demonstrates that the EDE can be used to distinguish between overweight women with and without BED (Wilfley et al. 2000). Because the EDE is available in the public domain, the clinician can incorporate subscales or items in the context of initial or ongoing clinical evaluations (Fairburn et al. 2008).

Several questionnaires can be used in the context of clinical evaluations to enhance the assessment of BED symptoms. The Eating Disorder Examination-Questionnaire (EDE-Q) (Fairburn and Beglin 2008) is a self-report questionnaire that was derived from the EDE to provide a more time- and cost-efficient alternative to the interview version. A number of research investigations have supported the reliability and validity of the EDE-Q as well as its correlation with the EDE interview (e.g., Berg et al. 2012). Another self-report questionnaire, the Eating Disorder Diagnostic Scale (EDDS) (Stice et al. 2000), is a 22-item measure that can be used to derive ED diagnoses or as a dimensional measure of symptom severity. Psychometric data support the reliability and validity of the EDDS (e.g., Stice et al. 2000). Finally, the Binge Eating Scale (BES) (Gormally et al. 1982) is a 16-item self-report questionnaire used to measure the presence and severity of BE symptoms. BES scores can be used categorically to identify potential binge eaters and/or as an initial and ongoing measure of BE severity. Research has supported the reliability and the validity of the BES (Gormally et al. 1982) and suggests that the BED may be a useful screening instrument for BED (e.g., Greeno et al. 1995), provided that a follow-up assessment is used to confirm a BED diagnosis.

Conclusion

In summary, it is recommended that symptoms of BED are assessed in all patients presenting to treatment regardless of their clinical or demographic characteristics. When conducted effectively, assessment can determine the presence and severity of BED symptoms, enhance the clinical relationship, and inform treatment planning and outcome evaluation in BED. Screening for BED symptoms can be easily integrated into clinical interviews and when indicated, further assessment can be used to determine the presence and frequency of BE episodes. Assessment of co-occurring symptoms including distress about eating, weight status, and compensatory behaviors are essential for assigning an accurate diagnosis as they may indicate a different type of ED. Assessing BED can be particularly challenging in youth and culturally diverse populations given the complexity of some of the diagnostic concepts. The use of open-ended questions, collaborative clarification, concrete examples, and structured assessment tools can enhance the accuracy of assessment.

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We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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