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Beating obesity: Help patients control binge eating disorder and night eating syndrome
Say “eating disorders,” and young, thin, Caucasian women with anorexia or bulimia nervosa come to mind. Psychiatry outpatients, however, are more likely to have binge eating disorder (BED) or night eating syndrome (NES) and to be middle-aged, obese, male, or African-American.
Like anorexia and bulimia, BED and NES cause distress, impairment, and medical morbidity. But BED and NES are different because you can manage many patients without referring them to eating disorder treatment centers. You can improve patients’ function and quality of life by:
- correcting eating disorder behaviors and thoughts
- identifying and managing psychiatric comorbidity
- identifying and treating associated medical problems (usually obesity complications such as diabetes mellitus, hypertension, and dyslipidemia)
- helping them achieve and maintain a healthy (but realistic) body weight.
Characteristics of BED and NES
BED and NES are coded as eating disorder, not otherwise specified in DSM-IV-TR, and their diagnostic criteria are provisional. Research criteria for BED are listed in Appendix B of DSM-IV (Box 1); diagnostic criteria for NES are being developed (Box 2).
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
- A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating)
- The binge-eating episodes are associated with three (or more) of the following:
- Eating much more rapidly than normal
- Eating until feeling uncomfortably full
- Eating large amounts of food when not feeling physically hungry
- Eating alone because of being embarrassed by how much one is eating
- Feeling disgusted with oneself, depressed, or very guilty after overeating
- Marked distress regarding binge eating is present.
- The binge eating occurs, on average, at least 2 days a week for 6 months.
- Binge eating is not associated with the regular use of inappropriate compensatory behaviors (eg, purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
Source: American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
- Morning anorexia, even if the patient eats breakfast
- Evening hyperphagia, in which ≥50% of daily energy intake is consumed after the evening meal
- Awakening at least once a night and eating snacks
- Duration of at least 3 months
- Patient does not meet criteria for bulimia nervosa or binge eating disorder
Source: Birketvedt GS, Florholmen J, Sundsfjord J, et al. Behavioral and neuroendocrine characteristics of the night-eating syndrome. JAMA 1999;282:657-63.
Prevalence. How common are these eating disorders? Two small studies examined BED and NES prevalence in outpatient psychiatric populations. A European study found 4% of 234 psychiatry clinic patients met criteria for BED,1 whereas 12% in 399 patients in two U.S. clinics met criteria for NES (with possibly higher rates in patients who took atypical antipsychotics).2
Demographics. Men experience BED and NES nearly as often as women, and distribution among women is similar across age groups.3 Binge eating may be more common among African-Americans than Caucasians.4
Obesity. One-half or more of persons with BED or NES are obese, with body mass index (BMI) ≥30.5,6 Obesity prevalence increases over time—from 22% at baseline to 39% 5 years later in one study of BED.7
Psychiatric comorbidity. Overweight or obesity increase the risk for early mortality and impaired quality of life.8 Persons with obesity plus BED have poorer physical and psychosocial function and lower quality of life than do obese persons without BED.9
Structured clinical interviews of 128 obese subjects found higher rates of psychiatric disorders in those with BED. Obesity with comorbid binge eating increased lifetime relative risk:
- >6-fold for major depression
- >8-fold for panic disorder
- >13-fold for borderline personality disorder, compared with obesity alone.10
Similarly, overweight patients with NES have more depression, lower self-esteem, and more difficulty losing weight than those without NES.11 They meet criteria significantly more often for major depressive disorder, anxiety disorders, and substance use disorders.12 Most NES patients view their nocturnal eating as shameful,13 and distress and guilt are among the diagnostic criteria for BED.
Fortunately, successful treatment of BED or NES almost always improves comorbid medical and psychiatric conditions as well. Ongoing treatment is critical for sustaining weight loss.14
Diagnosis and evaluation
Start by asking overweight patients if they binge eat or do most of their eating at night. Follow up with questions to assess whether they meet provisional diagnostic criteria for BED or NES and to rule out other disorders in the differential diagnosis (Box 3). These include bulimia and sleep-related eating disorder, which is generally regarded as a parasomnia.
Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.15 Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).16 Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.
| Disorder | Bulimia nervosa | Binge eating disorder | Night-eating syndrome | Sleep-related eating disorder |
|---|---|---|---|---|
| Morning anorexia | No | No | Yes | Yes |
| Evening hyperphagia | No | No | Yes | No |
| Eating pattern | Binges | Binges | Snacks | Snacks, unusual items |
| Compensatory behavior | Yes | No | No | No |
| Awareness of eating | Yes | Yes | Yes | No |
| Polysomnography | Normal | Normal | Low sleep efficiency | Sleep disorder |
| Treatment | CBT, SSRIs | CBT, SSRIs | Sertraline, relaxation | Treat sleep disorder; dopamine agonists |
| CBT: cognitive-behavioral therapy | ||||
| SSRIs: selective serotonin reuptake inhibitors | ||||
Controlling binge eating
Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:
- The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
- Medications are less effective in reducing bingeing but are associated with modest weight loss.
Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.17 CBT techniques for BED adapt readily to self-help programs (Box 4).
In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:
- 46% with CBT
- 18.4% with behavioral weight loss
- 13.3% for controls.
Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.18 The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).
Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.
A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.19
Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.20
Self-monitor
- Keep detailed records of all dietary intake
- Look for patterns in timing, type, and amount of food eaten
- Note antecedents and consequences of binges
Eat regularly
- Have 3 planned meals and 2 snacks per day
- Reduce cues to eat at other times
Substitute other behaviors for bingeing
- List pleasant alternate activities
- Recognize urges to binge
- Choose a substitute activity
- Review efficacy of substitute behaviors in preventing binges
Revise erroneous thinking patterns
- Reduce unrealistic expectations (especially about weight loss)
- Minimize self-criticism in response to lapses
- Change polarized thinking (“I’ve blown my diet; I may as well binge.”)
Limit vulnerabilities to relapse
- Reduce concerns about weight and shape
- Address problems with self-esteem, depression, or anxiety
- Maintain realistic expectations
Source: Fairburn CG. Overcoming binge eating. New York: Guilford Press; 1995.
Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.
| Medication | Dosage (mg/d) | Duration (weeks) | N | BED remission (%) | Weight loss (kg)* | |
|---|---|---|---|---|---|---|
| Drug | Placebo | |||||
| Citalopram | 20 to 60 | 6 | 38 | 47 | 21 | 2.3 |
| Desipramine | 100 to 300 | 8 | 23 | 60 | 15 | 2.3 |
| Fluoxetine | 20 to 80 | 6 | 60 | 45 | 21 | 4.6 |
| Fluvoxamine | 50 to 300 | 9 | 85 | 38 | 26 | 1.7 |
| Orlistat | 120 tid | 24 | 89 | 23 | 29 | 5.1 |
| Sertraline | 50 to 200 | 6 | 34 | 47 | 14 | 4.4 |
| Sibutramine† | 15 | 12 | 60 | Not reported | 8.8 | |
| Topiramate | 50 to 600 | 14 | 58 | 64 | 30 | 4.8 |
| * Difference between weight lost with drug and weight lost with placebo | ||||||
| † Sibutramine is a controlled substance (schedule IV) and is recommended only for obese patients with BMI ≥30 (≥27 if cardiac risk factors are present). Do not use with monoamine oxidase inhibitors or serotonergic agents, and monitor blood pressure. | ||||||
| Source: Carter WP, Hudson JI, Lalonde JK, et al. Pharmacologic treatment of binge eating disorder. Int J Eat Disord 2003;34:S74-S88 | ||||||
Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:21
- Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
- Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
- Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.
Little is known about appropriate dosages and durations for treating BED. Based on bulimia studies, most experts recommend higher-than-usual SSRI dosing (such as fluoxetine, 60 mg/d) and continuing treatment at least 6 months.22
Behavioral weight-loss programs have not been evaluated for BED in randomized, controlled trials. Obese persons with BED experience weight loss equivalent to that of those without BED, however, and more than one-half of persons with BED stop bingeing.9
Most programs combine reduced-calorie diets, increased activity, and behavior modification. Obese patients typically experience a 10% weight loss across 4 months to 1 year, but without continued intervention their weight returns to baseline.23 Weight Watchers is one behavioral weight-loss program with documented efficacy in controlled trials.24
Advocating calorie restriction for binge-eating patients has been controversial because dieting plays a role in triggering and maintaining bulimia nervosa. Recent evidence suggests, however, that binge eating disorder can be safely managed with dieting. In a randomized, controlled trial, 123 obese women without BED were randomly assigned to 3 groups:
- 1,000 kcal/d liquid meal replacement
- 1,200 to 1,500 kcal/d diet of conventional food
- a non-dieting approach to weight control.
Weight and depressive symptoms declined significantly among women in the two dieting groups but not in non-dieters. More episodes of binge eating were observed in subjects on the liquid diet at week 28, but no differences were seen at weeks 40 and 65, and no subjects in any group developed bulimia or binge eating disorder.25
Surprisingly, a 2003 review found that weight loss treatment that ignores bingeing is as effective in reducing bingeing as treatment that focuses solely on that symptom.22
Recommendations. A variety of treatments may be effective for BED, but no guidelines exist to help you choose among them. CBT is considered the treatment of choice, but most overweight BED patients require adjunctive exercise, medication, or behavioral weight-loss treatment.
We recommend that you base each patient’s treatment on five factors:
- treatment availability and cost
- past treatment response
- patient preference
- psychiatric and medical comorbidities
- BMI and past weight-loss experience.
For example, self-help CBT plus exercise or orlistat might benefit an obese man with bipolar disorder who was unable to tolerate adjunctive topiramate. An overweight depressed woman who needs weight-loss support could be given sertraline and encouraged to attend Weight Watchers.
Educate patients about realistic weight loss goals. A reasonable expectation is to lose 0.5 to 2 lbs/week, for a 10% loss across 6 months. Refer to guidelines for obesity risk assessment and treatment23 when advising patients about exercise and weight loss.
Treating night eating syndrome
Research into NES is just beginning, and one small, randomized trial has been published. Twenty patients with NES were randomly assigned to sit quietly or practice progressive muscle relaxation 20 minutes/day for 1 week. Muscle relaxation was associated with improved stress, anxiety, and depression scores, along with trends toward reduced nocturnal eating.26
This study supports a role for stress and anxiety in NES and suggests a potentially effective treatment. These results need to be replicated, however. In other preliminary work:
- After 12 weeks of sertraline therapy (average 188 mg/d), 17 obese patients with NES were eating less often at night, taking in fewer calories after the evening meal, and awakening less often. Five patients (29%) experienced remission, with an average weight loss of 4.8 kg.27
- One of two NES patients treated with topiramate (mean dose 218 mg at night) experienced remission and the other a marked response. Sleep improved, and average weight loss was 11 kg across 8 months.28
- One woman, age 51, with NES and nonseasonal depression experienced remission of depression and NES after 14 phototherapy sessions. NES returned when light therapy was discontinued.29
Recommendations. Suggest that NES patients start progressive muscle relaxation (see Related resources for instructions, or patients can purchase audiotapes). If benefits are insufficient, consider adjunctive sertraline, topiramate, or phototherapy. The efficacy of self-help for NES has not been evaluated, although a manual is available (see Related resources).
For clinicians
- Devlin MJ, Yanovski SZ, Wilson GT. Obesity: What mental health professionals need to know. Am J Psychiatry 2000;157:854-66.
- Instructions for progressive muscle relaxation. www.webmd.com/hw/health_guide_atoz/ta4146.asp?navbar=hw153409.
For patients and clinicians
- Anorexia and related eating disorders. www.anred.com (information about BED and NES).
- Self-help manuals available at bookstores or at Gürze Books (www.gurze.com):
- Fairburn CG. Overcoming binge eating. New York: Guilford Press, 1995.
- Allison KC, Stunkard AJ, Thier SL. Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger Publications; 2004.
- Weight Control Information Network (WIN). National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov
Drug brand names
- Citalopram • Celexa
- Desipramine • Norpramin
- Fluoxetine • Prozac
- Orlistat • Xenical
- Sertraline • Zoloft
- Sibutramine • Meridia
- Topiramate • Topamax
Disclosures
Dr. Cloak owns Pfizer Inc. stock but otherwise reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Powers reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Taraldsen KW, Eriksen L, Gotestam KG. Prevalence of eating disorders among Norwegian women and men in a psychiatric outpatient unit. Int J Eat Disord 1996;20:185-90.
2. Lundgren JD, Allison KC, Crow S, et al. Prevalence of the night-eating syndrome in a psychiatric population. Am J Psychiatry 2006;163:156-8.
3. Streigel-Moore RH, Franko DL. Epidemiology of binge eating disorder. Int J Eating Disord 2003;34:S19-S29.
4. Striegel-Moore RH, Wilfley DE, Pike KM, et al. Recurrent binge eating in black American women. Arch Fam Med 2000;9:83-7.
5. Marshall HM, Allison KC, O’Reardon JP, et al. Night eating syndrome among nonobese persons. Int J Eat Disord 2004;35:217-22.
6. Spitzer RL, Yanovski S, Wadden T, et al. Binge eating disorder: its further validation in a multisite study. Int J Eat Disord 1993;13:137-53.
7. Fairburn CG, Cooper Z, Doll HA, et al. The natural course of bulimia nervosa and binge eating disorder in young women. Arch Gen Psychiatry 2000;37:659-65.
8. Fontaine KR, Redden DT, Wang C, et al. Years of life lost due to obesity. JAMA 2003;289:187-93.
9. Rieger E, Wilfley DE, Stein RI, et al. A comparison of quality of life in obese individuals with and without binge eating disorder. Int J Eat Disord 2005;37:234-40.
10. Yanovski SZ, Nelson JE, Dubbert BK, Spitzer RL. Association of binge eating disorder and psychiatric co-morbidity in obese subjects. Am J Psychiatry 1993;150:1472-9.
11. Gluck ME, Geliebter A, Satov T. Night eating syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less weight loss in obese outpatients. Obes Res 2001;9:264-7.
12. Stunkard AJ, Allison KC. Two forms of disordered eating in obesity: Binge eating and night eating. Int J Obes Relat Metab Disord 2003;7:1-12.
13. O’Reardon JP, Peshek A, Allison K. Night eating syndrome: Diagnosis, epidemiology, and management. CNS Drugs 2005;19:997-1008.
14. Agras WS, Teich CF, Arnow B, et al. One-year follow-up of cognitive-behavioral therapy for obese individuals with binge-eating disorder. J Consult Clin Psychol 1997;65:343-7.
15. Cloak NL, Powers PS. Are undiagnosed eating disorders keeping your patients sick? Current Psychiatry 2005;4(12):65-75.
16. Kushner RF, Roth JL. Medical evaluation of the obese individual. Psychiatr Clin North Am 2005;28:89-103.
17. Wonderlich SA, de Zwaan M, Mitchell JE, et al. Psychological and dietary treatments of binge eating disorder: conceptual implications. Int J Eat Disord 2003;34:S58-S73.
18. Grilo CM, Masheb RM. A randomized controlled comparison of guided self-help cognitive behavioral therapy and behavioral weight loss for binge-eating disorder. Behav Res Ther 2005;43:1509-25.
19. Wilfley DE, Welch RR, Stein RI, et al. A randomized comparison of group cognitive-behavioral therapy and group interpersonal therapy for the treatment of overweight individuals with binge eating disorder. Arch Gen Psychiatry 2002;59:713-21.
20. Telch CF, Agras WS, Linehan MM. Dialectical behavior therapy for binge eating disorder. J Consult Clin Psychol 2001;69:1061-5.
21. Pendleton VR, Goodrick CK, Poston WS, et al. Exercise augments the effects of cognitive-behavioral therapy in the treatment of binge eating. Int J Eat Disord 2002;31:172-84.
22. Agras WS. Pharmacotherapy of bulimia nervosa and binge eating disorder: longer-term outcomes. Psychopharmacol Bull 1997;33:433-6.
23. Clinical guidelines on the identification evaluation and treatment of obesity in adults Executive summary, 1998. Bethesda, MD: National Heart, Lung, and Blood Institute. Available at: http://www.nhlbi.nih.gov/guidelines/obesity. Accessed April 18, 2006.
24. Tsai AG, Wadden TA, Womble LG, Byrne KJ. Commercial and self-help programs for weight control. Psychiatr Clin North Am 2005;28:171-92.
25. Wadden TA, Foster GD, Sarwer DB, et al. Dieting and the development of eating disorders in obese women: Results of a randomized controlled trial. Am J Clin Nutr 2004;80:560-8.
26. Pawlow LA, O’Neil PM, Malcolm RJ. Night eating syndrome: Effects of brief relaxation training on stress, mood, hunger, and eating patterns. Int J Obes Relat Metab Disord 2003;27:970-8.
27. O’Reardon JP, Stunkard AJ, Allison KC. A clinical trial of sertraline in the treatment of night eating syndrome. Int J Eat Disord 2004;35:16-26.
28. Winkelman JW. Treatment of nocturnal eating syndrome and sleep-related eating disorder with topiramate. Sleep Med 2003;4(3):243-6.
29. Friedman S, Even C, Dardennes R, Guelfi JD. Light therapy, obesity, and night-eating syndrome. Am J Psychiatry 2002;159:875-6.
Say “eating disorders,” and young, thin, Caucasian women with anorexia or bulimia nervosa come to mind. Psychiatry outpatients, however, are more likely to have binge eating disorder (BED) or night eating syndrome (NES) and to be middle-aged, obese, male, or African-American.
Like anorexia and bulimia, BED and NES cause distress, impairment, and medical morbidity. But BED and NES are different because you can manage many patients without referring them to eating disorder treatment centers. You can improve patients’ function and quality of life by:
- correcting eating disorder behaviors and thoughts
- identifying and managing psychiatric comorbidity
- identifying and treating associated medical problems (usually obesity complications such as diabetes mellitus, hypertension, and dyslipidemia)
- helping them achieve and maintain a healthy (but realistic) body weight.
Characteristics of BED and NES
BED and NES are coded as eating disorder, not otherwise specified in DSM-IV-TR, and their diagnostic criteria are provisional. Research criteria for BED are listed in Appendix B of DSM-IV (Box 1); diagnostic criteria for NES are being developed (Box 2).
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
- A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating)
- The binge-eating episodes are associated with three (or more) of the following:
- Eating much more rapidly than normal
- Eating until feeling uncomfortably full
- Eating large amounts of food when not feeling physically hungry
- Eating alone because of being embarrassed by how much one is eating
- Feeling disgusted with oneself, depressed, or very guilty after overeating
- Marked distress regarding binge eating is present.
- The binge eating occurs, on average, at least 2 days a week for 6 months.
- Binge eating is not associated with the regular use of inappropriate compensatory behaviors (eg, purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
Source: American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
- Morning anorexia, even if the patient eats breakfast
- Evening hyperphagia, in which ≥50% of daily energy intake is consumed after the evening meal
- Awakening at least once a night and eating snacks
- Duration of at least 3 months
- Patient does not meet criteria for bulimia nervosa or binge eating disorder
Source: Birketvedt GS, Florholmen J, Sundsfjord J, et al. Behavioral and neuroendocrine characteristics of the night-eating syndrome. JAMA 1999;282:657-63.
Prevalence. How common are these eating disorders? Two small studies examined BED and NES prevalence in outpatient psychiatric populations. A European study found 4% of 234 psychiatry clinic patients met criteria for BED,1 whereas 12% in 399 patients in two U.S. clinics met criteria for NES (with possibly higher rates in patients who took atypical antipsychotics).2
Demographics. Men experience BED and NES nearly as often as women, and distribution among women is similar across age groups.3 Binge eating may be more common among African-Americans than Caucasians.4
Obesity. One-half or more of persons with BED or NES are obese, with body mass index (BMI) ≥30.5,6 Obesity prevalence increases over time—from 22% at baseline to 39% 5 years later in one study of BED.7
Psychiatric comorbidity. Overweight or obesity increase the risk for early mortality and impaired quality of life.8 Persons with obesity plus BED have poorer physical and psychosocial function and lower quality of life than do obese persons without BED.9
Structured clinical interviews of 128 obese subjects found higher rates of psychiatric disorders in those with BED. Obesity with comorbid binge eating increased lifetime relative risk:
- >6-fold for major depression
- >8-fold for panic disorder
- >13-fold for borderline personality disorder, compared with obesity alone.10
Similarly, overweight patients with NES have more depression, lower self-esteem, and more difficulty losing weight than those without NES.11 They meet criteria significantly more often for major depressive disorder, anxiety disorders, and substance use disorders.12 Most NES patients view their nocturnal eating as shameful,13 and distress and guilt are among the diagnostic criteria for BED.
Fortunately, successful treatment of BED or NES almost always improves comorbid medical and psychiatric conditions as well. Ongoing treatment is critical for sustaining weight loss.14
Diagnosis and evaluation
Start by asking overweight patients if they binge eat or do most of their eating at night. Follow up with questions to assess whether they meet provisional diagnostic criteria for BED or NES and to rule out other disorders in the differential diagnosis (Box 3). These include bulimia and sleep-related eating disorder, which is generally regarded as a parasomnia.
Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.15 Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).16 Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.
| Disorder | Bulimia nervosa | Binge eating disorder | Night-eating syndrome | Sleep-related eating disorder |
|---|---|---|---|---|
| Morning anorexia | No | No | Yes | Yes |
| Evening hyperphagia | No | No | Yes | No |
| Eating pattern | Binges | Binges | Snacks | Snacks, unusual items |
| Compensatory behavior | Yes | No | No | No |
| Awareness of eating | Yes | Yes | Yes | No |
| Polysomnography | Normal | Normal | Low sleep efficiency | Sleep disorder |
| Treatment | CBT, SSRIs | CBT, SSRIs | Sertraline, relaxation | Treat sleep disorder; dopamine agonists |
| CBT: cognitive-behavioral therapy | ||||
| SSRIs: selective serotonin reuptake inhibitors | ||||
Controlling binge eating
Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:
- The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
- Medications are less effective in reducing bingeing but are associated with modest weight loss.
Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.17 CBT techniques for BED adapt readily to self-help programs (Box 4).
In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:
- 46% with CBT
- 18.4% with behavioral weight loss
- 13.3% for controls.
Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.18 The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).
Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.
A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.19
Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.20
Self-monitor
- Keep detailed records of all dietary intake
- Look for patterns in timing, type, and amount of food eaten
- Note antecedents and consequences of binges
Eat regularly
- Have 3 planned meals and 2 snacks per day
- Reduce cues to eat at other times
Substitute other behaviors for bingeing
- List pleasant alternate activities
- Recognize urges to binge
- Choose a substitute activity
- Review efficacy of substitute behaviors in preventing binges
Revise erroneous thinking patterns
- Reduce unrealistic expectations (especially about weight loss)
- Minimize self-criticism in response to lapses
- Change polarized thinking (“I’ve blown my diet; I may as well binge.”)
Limit vulnerabilities to relapse
- Reduce concerns about weight and shape
- Address problems with self-esteem, depression, or anxiety
- Maintain realistic expectations
Source: Fairburn CG. Overcoming binge eating. New York: Guilford Press; 1995.
Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.
| Medication | Dosage (mg/d) | Duration (weeks) | N | BED remission (%) | Weight loss (kg)* | |
|---|---|---|---|---|---|---|
| Drug | Placebo | |||||
| Citalopram | 20 to 60 | 6 | 38 | 47 | 21 | 2.3 |
| Desipramine | 100 to 300 | 8 | 23 | 60 | 15 | 2.3 |
| Fluoxetine | 20 to 80 | 6 | 60 | 45 | 21 | 4.6 |
| Fluvoxamine | 50 to 300 | 9 | 85 | 38 | 26 | 1.7 |
| Orlistat | 120 tid | 24 | 89 | 23 | 29 | 5.1 |
| Sertraline | 50 to 200 | 6 | 34 | 47 | 14 | 4.4 |
| Sibutramine† | 15 | 12 | 60 | Not reported | 8.8 | |
| Topiramate | 50 to 600 | 14 | 58 | 64 | 30 | 4.8 |
| * Difference between weight lost with drug and weight lost with placebo | ||||||
| † Sibutramine is a controlled substance (schedule IV) and is recommended only for obese patients with BMI ≥30 (≥27 if cardiac risk factors are present). Do not use with monoamine oxidase inhibitors or serotonergic agents, and monitor blood pressure. | ||||||
| Source: Carter WP, Hudson JI, Lalonde JK, et al. Pharmacologic treatment of binge eating disorder. Int J Eat Disord 2003;34:S74-S88 | ||||||
Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:21
- Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
- Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
- Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.
Little is known about appropriate dosages and durations for treating BED. Based on bulimia studies, most experts recommend higher-than-usual SSRI dosing (such as fluoxetine, 60 mg/d) and continuing treatment at least 6 months.22
Behavioral weight-loss programs have not been evaluated for BED in randomized, controlled trials. Obese persons with BED experience weight loss equivalent to that of those without BED, however, and more than one-half of persons with BED stop bingeing.9
Most programs combine reduced-calorie diets, increased activity, and behavior modification. Obese patients typically experience a 10% weight loss across 4 months to 1 year, but without continued intervention their weight returns to baseline.23 Weight Watchers is one behavioral weight-loss program with documented efficacy in controlled trials.24
Advocating calorie restriction for binge-eating patients has been controversial because dieting plays a role in triggering and maintaining bulimia nervosa. Recent evidence suggests, however, that binge eating disorder can be safely managed with dieting. In a randomized, controlled trial, 123 obese women without BED were randomly assigned to 3 groups:
- 1,000 kcal/d liquid meal replacement
- 1,200 to 1,500 kcal/d diet of conventional food
- a non-dieting approach to weight control.
Weight and depressive symptoms declined significantly among women in the two dieting groups but not in non-dieters. More episodes of binge eating were observed in subjects on the liquid diet at week 28, but no differences were seen at weeks 40 and 65, and no subjects in any group developed bulimia or binge eating disorder.25
Surprisingly, a 2003 review found that weight loss treatment that ignores bingeing is as effective in reducing bingeing as treatment that focuses solely on that symptom.22
Recommendations. A variety of treatments may be effective for BED, but no guidelines exist to help you choose among them. CBT is considered the treatment of choice, but most overweight BED patients require adjunctive exercise, medication, or behavioral weight-loss treatment.
We recommend that you base each patient’s treatment on five factors:
- treatment availability and cost
- past treatment response
- patient preference
- psychiatric and medical comorbidities
- BMI and past weight-loss experience.
For example, self-help CBT plus exercise or orlistat might benefit an obese man with bipolar disorder who was unable to tolerate adjunctive topiramate. An overweight depressed woman who needs weight-loss support could be given sertraline and encouraged to attend Weight Watchers.
Educate patients about realistic weight loss goals. A reasonable expectation is to lose 0.5 to 2 lbs/week, for a 10% loss across 6 months. Refer to guidelines for obesity risk assessment and treatment23 when advising patients about exercise and weight loss.
Treating night eating syndrome
Research into NES is just beginning, and one small, randomized trial has been published. Twenty patients with NES were randomly assigned to sit quietly or practice progressive muscle relaxation 20 minutes/day for 1 week. Muscle relaxation was associated with improved stress, anxiety, and depression scores, along with trends toward reduced nocturnal eating.26
This study supports a role for stress and anxiety in NES and suggests a potentially effective treatment. These results need to be replicated, however. In other preliminary work:
- After 12 weeks of sertraline therapy (average 188 mg/d), 17 obese patients with NES were eating less often at night, taking in fewer calories after the evening meal, and awakening less often. Five patients (29%) experienced remission, with an average weight loss of 4.8 kg.27
- One of two NES patients treated with topiramate (mean dose 218 mg at night) experienced remission and the other a marked response. Sleep improved, and average weight loss was 11 kg across 8 months.28
- One woman, age 51, with NES and nonseasonal depression experienced remission of depression and NES after 14 phototherapy sessions. NES returned when light therapy was discontinued.29
Recommendations. Suggest that NES patients start progressive muscle relaxation (see Related resources for instructions, or patients can purchase audiotapes). If benefits are insufficient, consider adjunctive sertraline, topiramate, or phototherapy. The efficacy of self-help for NES has not been evaluated, although a manual is available (see Related resources).
For clinicians
- Devlin MJ, Yanovski SZ, Wilson GT. Obesity: What mental health professionals need to know. Am J Psychiatry 2000;157:854-66.
- Instructions for progressive muscle relaxation. www.webmd.com/hw/health_guide_atoz/ta4146.asp?navbar=hw153409.
For patients and clinicians
- Anorexia and related eating disorders. www.anred.com (information about BED and NES).
- Self-help manuals available at bookstores or at Gürze Books (www.gurze.com):
- Fairburn CG. Overcoming binge eating. New York: Guilford Press, 1995.
- Allison KC, Stunkard AJ, Thier SL. Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger Publications; 2004.
- Weight Control Information Network (WIN). National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov
Drug brand names
- Citalopram • Celexa
- Desipramine • Norpramin
- Fluoxetine • Prozac
- Orlistat • Xenical
- Sertraline • Zoloft
- Sibutramine • Meridia
- Topiramate • Topamax
Disclosures
Dr. Cloak owns Pfizer Inc. stock but otherwise reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Powers reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Say “eating disorders,” and young, thin, Caucasian women with anorexia or bulimia nervosa come to mind. Psychiatry outpatients, however, are more likely to have binge eating disorder (BED) or night eating syndrome (NES) and to be middle-aged, obese, male, or African-American.
Like anorexia and bulimia, BED and NES cause distress, impairment, and medical morbidity. But BED and NES are different because you can manage many patients without referring them to eating disorder treatment centers. You can improve patients’ function and quality of life by:
- correcting eating disorder behaviors and thoughts
- identifying and managing psychiatric comorbidity
- identifying and treating associated medical problems (usually obesity complications such as diabetes mellitus, hypertension, and dyslipidemia)
- helping them achieve and maintain a healthy (but realistic) body weight.
Characteristics of BED and NES
BED and NES are coded as eating disorder, not otherwise specified in DSM-IV-TR, and their diagnostic criteria are provisional. Research criteria for BED are listed in Appendix B of DSM-IV (Box 1); diagnostic criteria for NES are being developed (Box 2).
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
- A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating)
- The binge-eating episodes are associated with three (or more) of the following:
- Eating much more rapidly than normal
- Eating until feeling uncomfortably full
- Eating large amounts of food when not feeling physically hungry
- Eating alone because of being embarrassed by how much one is eating
- Feeling disgusted with oneself, depressed, or very guilty after overeating
- Marked distress regarding binge eating is present.
- The binge eating occurs, on average, at least 2 days a week for 6 months.
- Binge eating is not associated with the regular use of inappropriate compensatory behaviors (eg, purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
Source: American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
- Morning anorexia, even if the patient eats breakfast
- Evening hyperphagia, in which ≥50% of daily energy intake is consumed after the evening meal
- Awakening at least once a night and eating snacks
- Duration of at least 3 months
- Patient does not meet criteria for bulimia nervosa or binge eating disorder
Source: Birketvedt GS, Florholmen J, Sundsfjord J, et al. Behavioral and neuroendocrine characteristics of the night-eating syndrome. JAMA 1999;282:657-63.
Prevalence. How common are these eating disorders? Two small studies examined BED and NES prevalence in outpatient psychiatric populations. A European study found 4% of 234 psychiatry clinic patients met criteria for BED,1 whereas 12% in 399 patients in two U.S. clinics met criteria for NES (with possibly higher rates in patients who took atypical antipsychotics).2
Demographics. Men experience BED and NES nearly as often as women, and distribution among women is similar across age groups.3 Binge eating may be more common among African-Americans than Caucasians.4
Obesity. One-half or more of persons with BED or NES are obese, with body mass index (BMI) ≥30.5,6 Obesity prevalence increases over time—from 22% at baseline to 39% 5 years later in one study of BED.7
Psychiatric comorbidity. Overweight or obesity increase the risk for early mortality and impaired quality of life.8 Persons with obesity plus BED have poorer physical and psychosocial function and lower quality of life than do obese persons without BED.9
Structured clinical interviews of 128 obese subjects found higher rates of psychiatric disorders in those with BED. Obesity with comorbid binge eating increased lifetime relative risk:
- >6-fold for major depression
- >8-fold for panic disorder
- >13-fold for borderline personality disorder, compared with obesity alone.10
Similarly, overweight patients with NES have more depression, lower self-esteem, and more difficulty losing weight than those without NES.11 They meet criteria significantly more often for major depressive disorder, anxiety disorders, and substance use disorders.12 Most NES patients view their nocturnal eating as shameful,13 and distress and guilt are among the diagnostic criteria for BED.
Fortunately, successful treatment of BED or NES almost always improves comorbid medical and psychiatric conditions as well. Ongoing treatment is critical for sustaining weight loss.14
Diagnosis and evaluation
Start by asking overweight patients if they binge eat or do most of their eating at night. Follow up with questions to assess whether they meet provisional diagnostic criteria for BED or NES and to rule out other disorders in the differential diagnosis (Box 3). These include bulimia and sleep-related eating disorder, which is generally regarded as a parasomnia.
Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.15 Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).16 Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.
| Disorder | Bulimia nervosa | Binge eating disorder | Night-eating syndrome | Sleep-related eating disorder |
|---|---|---|---|---|
| Morning anorexia | No | No | Yes | Yes |
| Evening hyperphagia | No | No | Yes | No |
| Eating pattern | Binges | Binges | Snacks | Snacks, unusual items |
| Compensatory behavior | Yes | No | No | No |
| Awareness of eating | Yes | Yes | Yes | No |
| Polysomnography | Normal | Normal | Low sleep efficiency | Sleep disorder |
| Treatment | CBT, SSRIs | CBT, SSRIs | Sertraline, relaxation | Treat sleep disorder; dopamine agonists |
| CBT: cognitive-behavioral therapy | ||||
| SSRIs: selective serotonin reuptake inhibitors | ||||
Controlling binge eating
Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:
- The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
- Medications are less effective in reducing bingeing but are associated with modest weight loss.
Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.17 CBT techniques for BED adapt readily to self-help programs (Box 4).
In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:
- 46% with CBT
- 18.4% with behavioral weight loss
- 13.3% for controls.
Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.18 The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).
Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.
A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.19
Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.20
Self-monitor
- Keep detailed records of all dietary intake
- Look for patterns in timing, type, and amount of food eaten
- Note antecedents and consequences of binges
Eat regularly
- Have 3 planned meals and 2 snacks per day
- Reduce cues to eat at other times
Substitute other behaviors for bingeing
- List pleasant alternate activities
- Recognize urges to binge
- Choose a substitute activity
- Review efficacy of substitute behaviors in preventing binges
Revise erroneous thinking patterns
- Reduce unrealistic expectations (especially about weight loss)
- Minimize self-criticism in response to lapses
- Change polarized thinking (“I’ve blown my diet; I may as well binge.”)
Limit vulnerabilities to relapse
- Reduce concerns about weight and shape
- Address problems with self-esteem, depression, or anxiety
- Maintain realistic expectations
Source: Fairburn CG. Overcoming binge eating. New York: Guilford Press; 1995.
Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.
| Medication | Dosage (mg/d) | Duration (weeks) | N | BED remission (%) | Weight loss (kg)* | |
|---|---|---|---|---|---|---|
| Drug | Placebo | |||||
| Citalopram | 20 to 60 | 6 | 38 | 47 | 21 | 2.3 |
| Desipramine | 100 to 300 | 8 | 23 | 60 | 15 | 2.3 |
| Fluoxetine | 20 to 80 | 6 | 60 | 45 | 21 | 4.6 |
| Fluvoxamine | 50 to 300 | 9 | 85 | 38 | 26 | 1.7 |
| Orlistat | 120 tid | 24 | 89 | 23 | 29 | 5.1 |
| Sertraline | 50 to 200 | 6 | 34 | 47 | 14 | 4.4 |
| Sibutramine† | 15 | 12 | 60 | Not reported | 8.8 | |
| Topiramate | 50 to 600 | 14 | 58 | 64 | 30 | 4.8 |
| * Difference between weight lost with drug and weight lost with placebo | ||||||
| † Sibutramine is a controlled substance (schedule IV) and is recommended only for obese patients with BMI ≥30 (≥27 if cardiac risk factors are present). Do not use with monoamine oxidase inhibitors or serotonergic agents, and monitor blood pressure. | ||||||
| Source: Carter WP, Hudson JI, Lalonde JK, et al. Pharmacologic treatment of binge eating disorder. Int J Eat Disord 2003;34:S74-S88 | ||||||
Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:21
- Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
- Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
- Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.
Little is known about appropriate dosages and durations for treating BED. Based on bulimia studies, most experts recommend higher-than-usual SSRI dosing (such as fluoxetine, 60 mg/d) and continuing treatment at least 6 months.22
Behavioral weight-loss programs have not been evaluated for BED in randomized, controlled trials. Obese persons with BED experience weight loss equivalent to that of those without BED, however, and more than one-half of persons with BED stop bingeing.9
Most programs combine reduced-calorie diets, increased activity, and behavior modification. Obese patients typically experience a 10% weight loss across 4 months to 1 year, but without continued intervention their weight returns to baseline.23 Weight Watchers is one behavioral weight-loss program with documented efficacy in controlled trials.24
Advocating calorie restriction for binge-eating patients has been controversial because dieting plays a role in triggering and maintaining bulimia nervosa. Recent evidence suggests, however, that binge eating disorder can be safely managed with dieting. In a randomized, controlled trial, 123 obese women without BED were randomly assigned to 3 groups:
- 1,000 kcal/d liquid meal replacement
- 1,200 to 1,500 kcal/d diet of conventional food
- a non-dieting approach to weight control.
Weight and depressive symptoms declined significantly among women in the two dieting groups but not in non-dieters. More episodes of binge eating were observed in subjects on the liquid diet at week 28, but no differences were seen at weeks 40 and 65, and no subjects in any group developed bulimia or binge eating disorder.25
Surprisingly, a 2003 review found that weight loss treatment that ignores bingeing is as effective in reducing bingeing as treatment that focuses solely on that symptom.22
Recommendations. A variety of treatments may be effective for BED, but no guidelines exist to help you choose among them. CBT is considered the treatment of choice, but most overweight BED patients require adjunctive exercise, medication, or behavioral weight-loss treatment.
We recommend that you base each patient’s treatment on five factors:
- treatment availability and cost
- past treatment response
- patient preference
- psychiatric and medical comorbidities
- BMI and past weight-loss experience.
For example, self-help CBT plus exercise or orlistat might benefit an obese man with bipolar disorder who was unable to tolerate adjunctive topiramate. An overweight depressed woman who needs weight-loss support could be given sertraline and encouraged to attend Weight Watchers.
Educate patients about realistic weight loss goals. A reasonable expectation is to lose 0.5 to 2 lbs/week, for a 10% loss across 6 months. Refer to guidelines for obesity risk assessment and treatment23 when advising patients about exercise and weight loss.
Treating night eating syndrome
Research into NES is just beginning, and one small, randomized trial has been published. Twenty patients with NES were randomly assigned to sit quietly or practice progressive muscle relaxation 20 minutes/day for 1 week. Muscle relaxation was associated with improved stress, anxiety, and depression scores, along with trends toward reduced nocturnal eating.26
This study supports a role for stress and anxiety in NES and suggests a potentially effective treatment. These results need to be replicated, however. In other preliminary work:
- After 12 weeks of sertraline therapy (average 188 mg/d), 17 obese patients with NES were eating less often at night, taking in fewer calories after the evening meal, and awakening less often. Five patients (29%) experienced remission, with an average weight loss of 4.8 kg.27
- One of two NES patients treated with topiramate (mean dose 218 mg at night) experienced remission and the other a marked response. Sleep improved, and average weight loss was 11 kg across 8 months.28
- One woman, age 51, with NES and nonseasonal depression experienced remission of depression and NES after 14 phototherapy sessions. NES returned when light therapy was discontinued.29
Recommendations. Suggest that NES patients start progressive muscle relaxation (see Related resources for instructions, or patients can purchase audiotapes). If benefits are insufficient, consider adjunctive sertraline, topiramate, or phototherapy. The efficacy of self-help for NES has not been evaluated, although a manual is available (see Related resources).
For clinicians
- Devlin MJ, Yanovski SZ, Wilson GT. Obesity: What mental health professionals need to know. Am J Psychiatry 2000;157:854-66.
- Instructions for progressive muscle relaxation. www.webmd.com/hw/health_guide_atoz/ta4146.asp?navbar=hw153409.
For patients and clinicians
- Anorexia and related eating disorders. www.anred.com (information about BED and NES).
- Self-help manuals available at bookstores or at Gürze Books (www.gurze.com):
- Fairburn CG. Overcoming binge eating. New York: Guilford Press, 1995.
- Allison KC, Stunkard AJ, Thier SL. Overcoming night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger Publications; 2004.
- Weight Control Information Network (WIN). National Institute of Diabetes and Digestive and Kidney Diseases. http://win.niddk.nih.gov
Drug brand names
- Citalopram • Celexa
- Desipramine • Norpramin
- Fluoxetine • Prozac
- Orlistat • Xenical
- Sertraline • Zoloft
- Sibutramine • Meridia
- Topiramate • Topamax
Disclosures
Dr. Cloak owns Pfizer Inc. stock but otherwise reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Powers reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Taraldsen KW, Eriksen L, Gotestam KG. Prevalence of eating disorders among Norwegian women and men in a psychiatric outpatient unit. Int J Eat Disord 1996;20:185-90.
2. Lundgren JD, Allison KC, Crow S, et al. Prevalence of the night-eating syndrome in a psychiatric population. Am J Psychiatry 2006;163:156-8.
3. Streigel-Moore RH, Franko DL. Epidemiology of binge eating disorder. Int J Eating Disord 2003;34:S19-S29.
4. Striegel-Moore RH, Wilfley DE, Pike KM, et al. Recurrent binge eating in black American women. Arch Fam Med 2000;9:83-7.
5. Marshall HM, Allison KC, O’Reardon JP, et al. Night eating syndrome among nonobese persons. Int J Eat Disord 2004;35:217-22.
6. Spitzer RL, Yanovski S, Wadden T, et al. Binge eating disorder: its further validation in a multisite study. Int J Eat Disord 1993;13:137-53.
7. Fairburn CG, Cooper Z, Doll HA, et al. The natural course of bulimia nervosa and binge eating disorder in young women. Arch Gen Psychiatry 2000;37:659-65.
8. Fontaine KR, Redden DT, Wang C, et al. Years of life lost due to obesity. JAMA 2003;289:187-93.
9. Rieger E, Wilfley DE, Stein RI, et al. A comparison of quality of life in obese individuals with and without binge eating disorder. Int J Eat Disord 2005;37:234-40.
10. Yanovski SZ, Nelson JE, Dubbert BK, Spitzer RL. Association of binge eating disorder and psychiatric co-morbidity in obese subjects. Am J Psychiatry 1993;150:1472-9.
11. Gluck ME, Geliebter A, Satov T. Night eating syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less weight loss in obese outpatients. Obes Res 2001;9:264-7.
12. Stunkard AJ, Allison KC. Two forms of disordered eating in obesity: Binge eating and night eating. Int J Obes Relat Metab Disord 2003;7:1-12.
13. O’Reardon JP, Peshek A, Allison K. Night eating syndrome: Diagnosis, epidemiology, and management. CNS Drugs 2005;19:997-1008.
14. Agras WS, Teich CF, Arnow B, et al. One-year follow-up of cognitive-behavioral therapy for obese individuals with binge-eating disorder. J Consult Clin Psychol 1997;65:343-7.
15. Cloak NL, Powers PS. Are undiagnosed eating disorders keeping your patients sick? Current Psychiatry 2005;4(12):65-75.
16. Kushner RF, Roth JL. Medical evaluation of the obese individual. Psychiatr Clin North Am 2005;28:89-103.
17. Wonderlich SA, de Zwaan M, Mitchell JE, et al. Psychological and dietary treatments of binge eating disorder: conceptual implications. Int J Eat Disord 2003;34:S58-S73.
18. Grilo CM, Masheb RM. A randomized controlled comparison of guided self-help cognitive behavioral therapy and behavioral weight loss for binge-eating disorder. Behav Res Ther 2005;43:1509-25.
19. Wilfley DE, Welch RR, Stein RI, et al. A randomized comparison of group cognitive-behavioral therapy and group interpersonal therapy for the treatment of overweight individuals with binge eating disorder. Arch Gen Psychiatry 2002;59:713-21.
20. Telch CF, Agras WS, Linehan MM. Dialectical behavior therapy for binge eating disorder. J Consult Clin Psychol 2001;69:1061-5.
21. Pendleton VR, Goodrick CK, Poston WS, et al. Exercise augments the effects of cognitive-behavioral therapy in the treatment of binge eating. Int J Eat Disord 2002;31:172-84.
22. Agras WS. Pharmacotherapy of bulimia nervosa and binge eating disorder: longer-term outcomes. Psychopharmacol Bull 1997;33:433-6.
23. Clinical guidelines on the identification evaluation and treatment of obesity in adults Executive summary, 1998. Bethesda, MD: National Heart, Lung, and Blood Institute. Available at: http://www.nhlbi.nih.gov/guidelines/obesity. Accessed April 18, 2006.
24. Tsai AG, Wadden TA, Womble LG, Byrne KJ. Commercial and self-help programs for weight control. Psychiatr Clin North Am 2005;28:171-92.
25. Wadden TA, Foster GD, Sarwer DB, et al. Dieting and the development of eating disorders in obese women: Results of a randomized controlled trial. Am J Clin Nutr 2004;80:560-8.
26. Pawlow LA, O’Neil PM, Malcolm RJ. Night eating syndrome: Effects of brief relaxation training on stress, mood, hunger, and eating patterns. Int J Obes Relat Metab Disord 2003;27:970-8.
27. O’Reardon JP, Stunkard AJ, Allison KC. A clinical trial of sertraline in the treatment of night eating syndrome. Int J Eat Disord 2004;35:16-26.
28. Winkelman JW. Treatment of nocturnal eating syndrome and sleep-related eating disorder with topiramate. Sleep Med 2003;4(3):243-6.
29. Friedman S, Even C, Dardennes R, Guelfi JD. Light therapy, obesity, and night-eating syndrome. Am J Psychiatry 2002;159:875-6.
1. Taraldsen KW, Eriksen L, Gotestam KG. Prevalence of eating disorders among Norwegian women and men in a psychiatric outpatient unit. Int J Eat Disord 1996;20:185-90.
2. Lundgren JD, Allison KC, Crow S, et al. Prevalence of the night-eating syndrome in a psychiatric population. Am J Psychiatry 2006;163:156-8.
3. Streigel-Moore RH, Franko DL. Epidemiology of binge eating disorder. Int J Eating Disord 2003;34:S19-S29.
4. Striegel-Moore RH, Wilfley DE, Pike KM, et al. Recurrent binge eating in black American women. Arch Fam Med 2000;9:83-7.
5. Marshall HM, Allison KC, O’Reardon JP, et al. Night eating syndrome among nonobese persons. Int J Eat Disord 2004;35:217-22.
6. Spitzer RL, Yanovski S, Wadden T, et al. Binge eating disorder: its further validation in a multisite study. Int J Eat Disord 1993;13:137-53.
7. Fairburn CG, Cooper Z, Doll HA, et al. The natural course of bulimia nervosa and binge eating disorder in young women. Arch Gen Psychiatry 2000;37:659-65.
8. Fontaine KR, Redden DT, Wang C, et al. Years of life lost due to obesity. JAMA 2003;289:187-93.
9. Rieger E, Wilfley DE, Stein RI, et al. A comparison of quality of life in obese individuals with and without binge eating disorder. Int J Eat Disord 2005;37:234-40.
10. Yanovski SZ, Nelson JE, Dubbert BK, Spitzer RL. Association of binge eating disorder and psychiatric co-morbidity in obese subjects. Am J Psychiatry 1993;150:1472-9.
11. Gluck ME, Geliebter A, Satov T. Night eating syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less weight loss in obese outpatients. Obes Res 2001;9:264-7.
12. Stunkard AJ, Allison KC. Two forms of disordered eating in obesity: Binge eating and night eating. Int J Obes Relat Metab Disord 2003;7:1-12.
13. O’Reardon JP, Peshek A, Allison K. Night eating syndrome: Diagnosis, epidemiology, and management. CNS Drugs 2005;19:997-1008.
14. Agras WS, Teich CF, Arnow B, et al. One-year follow-up of cognitive-behavioral therapy for obese individuals with binge-eating disorder. J Consult Clin Psychol 1997;65:343-7.
15. Cloak NL, Powers PS. Are undiagnosed eating disorders keeping your patients sick? Current Psychiatry 2005;4(12):65-75.
16. Kushner RF, Roth JL. Medical evaluation of the obese individual. Psychiatr Clin North Am 2005;28:89-103.
17. Wonderlich SA, de Zwaan M, Mitchell JE, et al. Psychological and dietary treatments of binge eating disorder: conceptual implications. Int J Eat Disord 2003;34:S58-S73.
18. Grilo CM, Masheb RM. A randomized controlled comparison of guided self-help cognitive behavioral therapy and behavioral weight loss for binge-eating disorder. Behav Res Ther 2005;43:1509-25.
19. Wilfley DE, Welch RR, Stein RI, et al. A randomized comparison of group cognitive-behavioral therapy and group interpersonal therapy for the treatment of overweight individuals with binge eating disorder. Arch Gen Psychiatry 2002;59:713-21.
20. Telch CF, Agras WS, Linehan MM. Dialectical behavior therapy for binge eating disorder. J Consult Clin Psychol 2001;69:1061-5.
21. Pendleton VR, Goodrick CK, Poston WS, et al. Exercise augments the effects of cognitive-behavioral therapy in the treatment of binge eating. Int J Eat Disord 2002;31:172-84.
22. Agras WS. Pharmacotherapy of bulimia nervosa and binge eating disorder: longer-term outcomes. Psychopharmacol Bull 1997;33:433-6.
23. Clinical guidelines on the identification evaluation and treatment of obesity in adults Executive summary, 1998. Bethesda, MD: National Heart, Lung, and Blood Institute. Available at: http://www.nhlbi.nih.gov/guidelines/obesity. Accessed April 18, 2006.
24. Tsai AG, Wadden TA, Womble LG, Byrne KJ. Commercial and self-help programs for weight control. Psychiatr Clin North Am 2005;28:171-92.
25. Wadden TA, Foster GD, Sarwer DB, et al. Dieting and the development of eating disorders in obese women: Results of a randomized controlled trial. Am J Clin Nutr 2004;80:560-8.
26. Pawlow LA, O’Neil PM, Malcolm RJ. Night eating syndrome: Effects of brief relaxation training on stress, mood, hunger, and eating patterns. Int J Obes Relat Metab Disord 2003;27:970-8.
27. O’Reardon JP, Stunkard AJ, Allison KC. A clinical trial of sertraline in the treatment of night eating syndrome. Int J Eat Disord 2004;35:16-26.
28. Winkelman JW. Treatment of nocturnal eating syndrome and sleep-related eating disorder with topiramate. Sleep Med 2003;4(3):243-6.
29. Friedman S, Even C, Dardennes R, Guelfi JD. Light therapy, obesity, and night-eating syndrome. Am J Psychiatry 2002;159:875-6.
Are undiagnosed eating disorders keeping your patients sick?
The internist next door asks you about his patient with bulimia, who routinely has potassium levels of 2.0 mEq/L. “She admits it’s a problem but thinks she’ll get fat if she stops purging. What can I tell her to get her into treatment?”
That afternoon, your longtime patient Mr. J—age 56 with depression, obesity, and hypertension—arrives for his appointment. With the day’s earlier conversation in mind, you ask him if he has an eating problem. Staring at the floor, he describes a lifelong battle with nighttime eating binges, which he has never mentioned to you before.
Mr. J may have concealed his binge eating because of shame or ambivalence about stopping a psychologically protective behavior. And his eating disorder may be complicating his depression treatment.
But outpatient psychiatrists can often manage patients like Mr. J in consultation with a nutritionist and primary care physician. Eating disorders are treatable,1,2 and many patients can recover. This article describes how to identify eating disorders so that treatment can begin.
Psychiatric comorbidity
Eating disorders are common in outpatient practice (Box)3,4 and coexist with a variety of psychiatric diagnoses (Table 1). For example, in 248 women with anorexia, bulimia, or unspecified eating disorders, 74% had another Axis I disorder, including:
- anxiety disorders (54%)
- affective disorders (52%)
- substance-related disorders (25%).
Eating disorders also are much more common in persons who present with psychiatric problems than in the general population. For example:
- Among 62 patients with a primary diagnosis of obsessive-compulsive disorder, 13% had anorexia or bulimia nervosa and another 18% met subthreshold criteria.6
- In 257 female patients with anxiety disorders, nearly 12% also met criteria for a possible eating disorder.7
Some 40% of persons with eating disorders meet DSM-IV-TR criteria for anorexia or bulimia nervosa. The other 60%—with eating disorder, not otherwise specified (ED-NOS)—are divided nearly evenly between binge eating disorder and subsyndromal anorexia or bulimia. Outpatient psychiatrists see these eating disorders most often.
Anorexia and bulimia nervosa prevalence rates are estimated to be 0.3% and 1%, respectively.3 But including ED-NOS patients increases the overall eating disorder prevalence to 2% to 3%—equal to or greater than the combined rates of schizophrenia and bipolar I disorder.
Although considered “subsyndromal,” ED-NOS patients suffer psychopathology, impairment, and medical comorbidity similar to those of persons who meet DSM-IV-TR criteria for anorexia or bulimia nervosa.4
Common psychiatric comorbidities in patients with eating disorders
| Disorder | Comorbidities |
|---|---|
| Anorexia and bulimia nervosa | Anxiety disorders (social phobia, PTSD, OCD) |
| Mood disorders (major depressive disorder, dysthymia, bipolar disorder) | |
| Substance use disorders (more common in patients who binge and/or purge) | |
| Personality disorders (cluster C more common in restricting anorexia, cluster B more common in patients who binge and purge) | |
| Binge eating disorder | Anxiety disorders (PTSD) |
| Mood disorders (major depressive disorder, bipolar disorder) | |
| PTSD: posttraumatic stress disorder | |
| OCD: obsessive-compulsive disorder | |
Who has eating disorders?
Most eating disorder patients are adolescent girls or young women with pronounced body image dissatisfaction. Other patients include:
Atypical young women. Some young women—usually Asian—meet most criteria for anorexia nervosa but lack the characteristic drive for thinness. They tend to have less psychopathology and better prognosis than typical female patients.9
Boys and men. Female-to-male ratios are approximately 11:1 for anorexia, 5:1 for bulimia, and 3:1 for binge eating disorder. Men and boys with eating disorders are similar to their female counterparts but are more likely to report:
- comorbid substance abuse
- having begun weight loss and purging in response to teasing or concerns about health, sports performance, or gay relationships, rather than appearance.10
Middle-aged to late-life. Midlife onset of eating disorders may be precipitated by losses or concerns about aging. In the elderly, eating disorders may be manifestations of complicated bereavement, and ruling out medical causes of weight loss is crucial in this age group.
Night-eating syndrome. Some patients eat at least 25% of daily calories after the evening meal. They experience insomnia, morning anorexia, and sometimes amnesia for the nocturnal eating episodes. Anxiety, depression, or sleep disorders may be contributing factors.12
Identifying eating disorders
Screening. No formal guidelines recommend which psychiatric patients to screen for eating disorders. We suggest screening any patients who are over- or underweight or have eating disorder risk factors, such as:
- young women (teens and early 20s)
- athletes in certain sports (gymnastics, ballet, figure skating, running, body building, wrestling)
- history of childhood sexual abuse.13
Interviewing. Evaluate all 4 illness domains—nutritional, medical, psychological, and social. Because patients often do not volunteer information, ask about:
- symptoms and complications
- onset and development of eating and weight problems
- history of being teased or criticized about weight
- weight history (premorbid, lowest, highest, and preferred weights).
DSM-IV-TR defines binging as consuming a large quantity of food in a discrete time and feeling out of control of eating. Ask specifically how the patient defines “binge,” and seek details of a typical binge. Also ask about compensatory behaviors (purging by vomiting or using laxatives or diuretics). Is the patient abusing ipecac, diet pills, or thyroid hormone? Does he or she fast or exercise compulsively (such as even while ill)?
Eating and exercise patterns. Ask the patient to recall everything eaten in the past 24 hours. This history can help estimate caloric intake and may reveal problematic eating patterns. For example, does the patient:
- avoid certain foods, consider others to be “safe,” or use diet products, gum, or mints?
- engage in food rituals, such as slow eating, hoarding food, or eating odd combinations?
- steal food, weigh him/herself frequently, or visit pro-anorexia/pro-bulimia Web sites?
Table 2
Potential medical complications of anorexia and bulimia nervosa
| Organ system | Symptoms | Signs, syndromes, laboratory abnormalities |
|---|---|---|
| Cardiovascular | Palpitations, dyspnea, chest pain, dizziness | Bradycardia, orthostasis, acrocyanosis |
| Prolonged PR and QTc intervals on ECG, mitral valve prolapse, cardiomyopathy in ipecac abusers | ||
| CNS | Anxious, depressed, or irritable mood; obsessiveness; cognitive deficits; seizures (rare) | Enlarged ventricles on CT or MRI, deficits on neuropsychological testing, abnormal EEG, signs of peripheral neuropathy |
| Dermatologic | Hair loss, dry skin | Xerosis, carotenoderma, cheilitis, lanugo, brittle hair and nails, Russell’s sign (callus on dorsum of hand used to induce vomiting) |
| Endocrine | Fatigue, cold intolerance | Hypothermia, hypoglycemia, hypercortisolemia, ↓ T3 and T4 |
| Gastrointestinal | Bloating, constipation, spontaneous vomiting, reflux, abdominal pain, heartburn, hematemesis | Abnormal bowel sounds, delayed gastric emptying, superior mesenteric artery syndrome, pancreatitis |
| In patients who vomit: Mallory-Weiss tears, Barrett’s esophagus, occult blood in stool, ↑ amylase, gingivitis, dental caries, sialadenosis, perimolysis | ||
| Genitourinary | Polyuria, oliguria | ↑ BUN, nephrolithiasis, hypokalemic nephropathy, renal failure (rare). |
| Hematologic | Fatigue, bruising | Anemia; ↓ numbers of WBCs, RBCs and platelets; ↓ ferritin, B12, folate |
| Metabolic | Weakness, cardiac or CNS manifestations | ↓ K, Na, Mg, phosphate; ↑ cholesterol; metabolic alkalosis (from vomiting), or acidosis (from laxatives); thiamin and niacin deficiencies (rare). |
| Musculoskeletal | Weakness, cramps, bone pain | Wasting, ↑ CK (rare), decreased bone mineral density, pathologic fractures |
| Reproductive | Amenorrhea, ↓ libido, infertility, ↑ pregnancy, neonatal complications | Arrested sexual development; ↓ estrogen or testosterone; prepubertal levels of LH and FSH |
Interview adjuncts
Assessment tools. In addition to patient interviews, some clinicians use self-report scales to screen for eating disorders or to monitor treatment. Reliable and valid self-report questionnaires include the Eating Disorder Examination-Q (36 items),14 Eating Disorder Inventory (91 items),15 and Eating Attitudes Test (26 items).16
The Eating Attitudes Test takes 10 minutes to complete and is widely used for screening. A cut-off score of 20 indicates a potential eating disorder and the need for a follow-up interview.
Self-report diaries can help identify binge eating triggers—usually dietary restriction combined with interpersonal stressors. Ask the patient to record all meals, snacks, binges, purges, and exercise activities, plus time of day and associated feelings, thoughts, and situations. Diaries can also reveal maladaptive thoughts, such as body image distortion, and problematic coping strategies, such as purging or excessive exercising.
Medical workup
Measure height and weight, calculate body mass index, and check vital signs (including supine and standing blood pressure and pulse) and hydration status. Perform a neurologic exam, particularly for peripheral neuropathy, and check for cardiac, dermatologic, and GI complications (Tables 2 and 3). Include a dental examination if the patient admits or you suspect self-induced vomiting.
If treating eating disorders’ medical consequences is beyond the scope of your practice, refer the patient for evaluation by a physician with this experience.
Table 3
Common medical complications of binge eating disorder
| Obesity (body mass index>30) and related comorbidities: |
| Hypertension |
| Diabetes mellitus |
| Hyperlipidemia |
| Increased cardiovascular mortality |
| Obstructive sleep apnea |
| Degenerative arthritis |
| Gastroesophageal reflux symptoms and complications |
- Weight for height in women: 100 lbs for the first 5 feet, +5 lbs/inch over 5 feet
- Weight for height in men: 106 lbs for the first 5 feet, +6 lbs/inch over 5 feet.
For adolescents with suspected anorexia nervosa, estimate expected body weight from individual growth curves or standard growth charts posted on the Centers for Disease Control and Prevention Web site (see Related resources).
Note that the DSM-IV-TR weight criterion for anorexia of “less than 85% of expected” is an example, not an absolute cutoff. Anorexia nervosa would be an appropriate diagnosis for a patient who weighs more than 85% of expected weight but has lost substantial weight and meets the other diagnostic criteria.
BMI
Laboratory tests vary, depending on patients’ suspected eating disorders (Table 4). In 214 outpatient women with anorexia, the most common abnormalities were anemia (38.6%), leukocytopenia (34.4%), hyponatremia (19.7%) and hypokalemia (19.7%).17 With few exceptions, abnormal values are not predicted by the apparent degree of undernutrition.
Table 4
Laboratory studies for patients with suspected eating disorders
| For whom | Recommended tests |
|---|---|
| All eating disorder patients | Comprehensive metabolic panel (electrolytes, glucose, albumin, measures of hepatic and renal function), complete blood count, urinalysis, ECG, TSH |
| Add for patients with anorexia | Serum magnesium, phosphate, calcium; creatinine clearance; chest radiography; estrogen in women, testosterone in men; DEXA bone density scan; consider echocardiography, brain MRI; screen urine for unreported substances of abuse |
| Add for patients with bulimia and purging type anorexia | Serum magnesium, phosphate, calcium; DEXA scan if patient is amenorrheic or has history of anorexia; amylase (fractionated, if possible); consider fecal occult blood, urine for electrolytes and laxatives, urine drug screen |
| Add for patients with binge eating disorder | Fasting blood glucose, fasting lipid profile |
From diagnosis to treatment
Talking with patients. Discussing abnormal lab results with patients can be therapeutic. In our experience, recovered patients often report that worry about medical complications was their primary reason to seek treatment for eating disorders.
Relate the patient’s cognitive, mood, and physical symptoms to abnormal eating behavior, then present the eating disorder diagnosis as the beginning of treatment. For example, you could praise Mr. J for his courage in revealing his binge eating and tell him that identifying this problem is the first step toward solving it. Not only can he overcome binge eating, but treatment will also likely improve his mood, weight, and blood pressure.
Eating disorder patients who are medically stable, motivated for treatment, have good support, and are able and willing to come for frequent appointments are good candidates for outpatient eating disorder treatment.
For clinicians
- Standard growth charts. National Center for Health Statistics. Centers for Disease Control and Prevention. www.cdc.gov/growthcharts.
- Brewerton TD. Clinical handbook of eating disorders: an integrated approach. New York: Marcel Dekker; 2004.
- Work group on eating disorders. Practice guideline for the treatment of patients with eating disorders (2nd ed.). Washington, DC: American Psychiatric Publishing; 2000. Available at: http://www.psych.org/psych_pract/treatg/pg/eating_revisebook_index.cfm.
- Zerbe KJ. The body betrayed: a deeper understanding of women, eating disorders, and treatment. Carlsbad, CA: Gürze Books; 1995.
- National Eating Disorders Association. www.nationaleatingdisorders.org.
- National Association of Anorexia Nervosa and Associated Disorders. www.anad.org.
1. Reas Dl, Williamson DA, Martin CK, Zucker NL. Duration of illness predicts outcome for bulimia nervosa: a long-term outcome study. Int J Eat Disord 2000;27:428-34.
2. Nielsen S, Moller-Madsen S, Isager T, et al. Standardized mortality in eating disorders—a quantitative summary of previously published and new evidence. J Psychosom Res 1998;44:413-34.
3. Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord 2003;34(4):383-96.
4. Watson TL, Andersen AE. A critical examination of the amenorrhea and weight criteria for diagnosing anorexia nervosa. Acta Psychiatr Scand 2003;108:175-82.
5. Milos G, Spindler A, Schnyder U. Psychiatric comorbidity and eating disorder inventory (EDI) profiles in eating disorder patients. Can J Psychiatry 2004;49:179-84.
6. Rubenstein CS, Pigott TA, L’ Heureux F, et al. A preliminary investigation of the lifetime prevalence of anorexia and bulimia nervosa in patients with obsessive compulsive disorder. J Clin Psychiatry 1992;53(9):309-14.
7. Becker CB, DeViva JC, Zayfert C. Eating disorder symptoms among female anxiety disorder patients in clinical practice: the importance of anxiety comorbidity assessment. J Anxiety Disord 2004;18(3):255-74.
8. Keys A, Brozek J, Henschel A, et al. The biology of human starvation. Minneapolis: University of Minnesota Press; 1950.
9. Ramacciotti CE, Dell’Osso L, Paoli RA, et al. Characteristics of eating disorder patients without a drive for thinness. Int J Eat Disord 2002;32:206-12.
10. Andersen AE. Males with eating disorders: medical considerations. In: Mehler PS, Andersen AE (eds). Eating disorders: a guide to medical care and complications. Baltimore: The Johns Hopkins University Press; 1999;214-26.
11. Lantzouni E, Frank GR, Golden NH, Shenker RI. Reversibility of growth stunting in early onset anorexia nervosa: a prospective study. J Adolesc Health 2002;31(2):162-5.
12. Napolitano MA, Head S, Babyak MA, Blumenthal JA. Binge eating disorder and night eating syndrome: psychological and behavioral characteristics. Int J Eating Disord 2001;30:193-203.
13. Jacobi C, Morris L, de Zwaan M. Overview of risk factors for anorexia nervosa, bulimia nervosa, and binge eating disorder. In: Brewerton, TD (ed). Clinical handbook of eating disorders: An integrated approach. New York: Marcel Dekker; 2004;183-208.
14. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire. Int J Eating Disord 1994;16:363-70.
15. Garner DM. Eating Disorder Inventory-2 professional manual. Odessa, FL: Psychological Assessment Resources; 1991.
16. Garner DM. Psychoeducational principles in treatment. In: Garner DM, Garfinkel PE (eds). Handbook of treatment for eating disorders (2nd ed). New York: Guilford Press; 1997;145-77.
17. Miller KK, Grinspoon SK, Ciampa J, et al. Medical findings in outpatients with anorexia nervosa. Arch Intern Med 2005;165(5):561-6.
The internist next door asks you about his patient with bulimia, who routinely has potassium levels of 2.0 mEq/L. “She admits it’s a problem but thinks she’ll get fat if she stops purging. What can I tell her to get her into treatment?”
That afternoon, your longtime patient Mr. J—age 56 with depression, obesity, and hypertension—arrives for his appointment. With the day’s earlier conversation in mind, you ask him if he has an eating problem. Staring at the floor, he describes a lifelong battle with nighttime eating binges, which he has never mentioned to you before.
Mr. J may have concealed his binge eating because of shame or ambivalence about stopping a psychologically protective behavior. And his eating disorder may be complicating his depression treatment.
But outpatient psychiatrists can often manage patients like Mr. J in consultation with a nutritionist and primary care physician. Eating disorders are treatable,1,2 and many patients can recover. This article describes how to identify eating disorders so that treatment can begin.
Psychiatric comorbidity
Eating disorders are common in outpatient practice (Box)3,4 and coexist with a variety of psychiatric diagnoses (Table 1). For example, in 248 women with anorexia, bulimia, or unspecified eating disorders, 74% had another Axis I disorder, including:
- anxiety disorders (54%)
- affective disorders (52%)
- substance-related disorders (25%).
Eating disorders also are much more common in persons who present with psychiatric problems than in the general population. For example:
- Among 62 patients with a primary diagnosis of obsessive-compulsive disorder, 13% had anorexia or bulimia nervosa and another 18% met subthreshold criteria.6
- In 257 female patients with anxiety disorders, nearly 12% also met criteria for a possible eating disorder.7
Some 40% of persons with eating disorders meet DSM-IV-TR criteria for anorexia or bulimia nervosa. The other 60%—with eating disorder, not otherwise specified (ED-NOS)—are divided nearly evenly between binge eating disorder and subsyndromal anorexia or bulimia. Outpatient psychiatrists see these eating disorders most often.
Anorexia and bulimia nervosa prevalence rates are estimated to be 0.3% and 1%, respectively.3 But including ED-NOS patients increases the overall eating disorder prevalence to 2% to 3%—equal to or greater than the combined rates of schizophrenia and bipolar I disorder.
Although considered “subsyndromal,” ED-NOS patients suffer psychopathology, impairment, and medical comorbidity similar to those of persons who meet DSM-IV-TR criteria for anorexia or bulimia nervosa.4
Common psychiatric comorbidities in patients with eating disorders
| Disorder | Comorbidities |
|---|---|
| Anorexia and bulimia nervosa | Anxiety disorders (social phobia, PTSD, OCD) |
| Mood disorders (major depressive disorder, dysthymia, bipolar disorder) | |
| Substance use disorders (more common in patients who binge and/or purge) | |
| Personality disorders (cluster C more common in restricting anorexia, cluster B more common in patients who binge and purge) | |
| Binge eating disorder | Anxiety disorders (PTSD) |
| Mood disorders (major depressive disorder, bipolar disorder) | |
| PTSD: posttraumatic stress disorder | |
| OCD: obsessive-compulsive disorder | |
Who has eating disorders?
Most eating disorder patients are adolescent girls or young women with pronounced body image dissatisfaction. Other patients include:
Atypical young women. Some young women—usually Asian—meet most criteria for anorexia nervosa but lack the characteristic drive for thinness. They tend to have less psychopathology and better prognosis than typical female patients.9
Boys and men. Female-to-male ratios are approximately 11:1 for anorexia, 5:1 for bulimia, and 3:1 for binge eating disorder. Men and boys with eating disorders are similar to their female counterparts but are more likely to report:
- comorbid substance abuse
- having begun weight loss and purging in response to teasing or concerns about health, sports performance, or gay relationships, rather than appearance.10
Middle-aged to late-life. Midlife onset of eating disorders may be precipitated by losses or concerns about aging. In the elderly, eating disorders may be manifestations of complicated bereavement, and ruling out medical causes of weight loss is crucial in this age group.
Night-eating syndrome. Some patients eat at least 25% of daily calories after the evening meal. They experience insomnia, morning anorexia, and sometimes amnesia for the nocturnal eating episodes. Anxiety, depression, or sleep disorders may be contributing factors.12
Identifying eating disorders
Screening. No formal guidelines recommend which psychiatric patients to screen for eating disorders. We suggest screening any patients who are over- or underweight or have eating disorder risk factors, such as:
- young women (teens and early 20s)
- athletes in certain sports (gymnastics, ballet, figure skating, running, body building, wrestling)
- history of childhood sexual abuse.13
Interviewing. Evaluate all 4 illness domains—nutritional, medical, psychological, and social. Because patients often do not volunteer information, ask about:
- symptoms and complications
- onset and development of eating and weight problems
- history of being teased or criticized about weight
- weight history (premorbid, lowest, highest, and preferred weights).
DSM-IV-TR defines binging as consuming a large quantity of food in a discrete time and feeling out of control of eating. Ask specifically how the patient defines “binge,” and seek details of a typical binge. Also ask about compensatory behaviors (purging by vomiting or using laxatives or diuretics). Is the patient abusing ipecac, diet pills, or thyroid hormone? Does he or she fast or exercise compulsively (such as even while ill)?
Eating and exercise patterns. Ask the patient to recall everything eaten in the past 24 hours. This history can help estimate caloric intake and may reveal problematic eating patterns. For example, does the patient:
- avoid certain foods, consider others to be “safe,” or use diet products, gum, or mints?
- engage in food rituals, such as slow eating, hoarding food, or eating odd combinations?
- steal food, weigh him/herself frequently, or visit pro-anorexia/pro-bulimia Web sites?
Table 2
Potential medical complications of anorexia and bulimia nervosa
| Organ system | Symptoms | Signs, syndromes, laboratory abnormalities |
|---|---|---|
| Cardiovascular | Palpitations, dyspnea, chest pain, dizziness | Bradycardia, orthostasis, acrocyanosis |
| Prolonged PR and QTc intervals on ECG, mitral valve prolapse, cardiomyopathy in ipecac abusers | ||
| CNS | Anxious, depressed, or irritable mood; obsessiveness; cognitive deficits; seizures (rare) | Enlarged ventricles on CT or MRI, deficits on neuropsychological testing, abnormal EEG, signs of peripheral neuropathy |
| Dermatologic | Hair loss, dry skin | Xerosis, carotenoderma, cheilitis, lanugo, brittle hair and nails, Russell’s sign (callus on dorsum of hand used to induce vomiting) |
| Endocrine | Fatigue, cold intolerance | Hypothermia, hypoglycemia, hypercortisolemia, ↓ T3 and T4 |
| Gastrointestinal | Bloating, constipation, spontaneous vomiting, reflux, abdominal pain, heartburn, hematemesis | Abnormal bowel sounds, delayed gastric emptying, superior mesenteric artery syndrome, pancreatitis |
| In patients who vomit: Mallory-Weiss tears, Barrett’s esophagus, occult blood in stool, ↑ amylase, gingivitis, dental caries, sialadenosis, perimolysis | ||
| Genitourinary | Polyuria, oliguria | ↑ BUN, nephrolithiasis, hypokalemic nephropathy, renal failure (rare). |
| Hematologic | Fatigue, bruising | Anemia; ↓ numbers of WBCs, RBCs and platelets; ↓ ferritin, B12, folate |
| Metabolic | Weakness, cardiac or CNS manifestations | ↓ K, Na, Mg, phosphate; ↑ cholesterol; metabolic alkalosis (from vomiting), or acidosis (from laxatives); thiamin and niacin deficiencies (rare). |
| Musculoskeletal | Weakness, cramps, bone pain | Wasting, ↑ CK (rare), decreased bone mineral density, pathologic fractures |
| Reproductive | Amenorrhea, ↓ libido, infertility, ↑ pregnancy, neonatal complications | Arrested sexual development; ↓ estrogen or testosterone; prepubertal levels of LH and FSH |
Interview adjuncts
Assessment tools. In addition to patient interviews, some clinicians use self-report scales to screen for eating disorders or to monitor treatment. Reliable and valid self-report questionnaires include the Eating Disorder Examination-Q (36 items),14 Eating Disorder Inventory (91 items),15 and Eating Attitudes Test (26 items).16
The Eating Attitudes Test takes 10 minutes to complete and is widely used for screening. A cut-off score of 20 indicates a potential eating disorder and the need for a follow-up interview.
Self-report diaries can help identify binge eating triggers—usually dietary restriction combined with interpersonal stressors. Ask the patient to record all meals, snacks, binges, purges, and exercise activities, plus time of day and associated feelings, thoughts, and situations. Diaries can also reveal maladaptive thoughts, such as body image distortion, and problematic coping strategies, such as purging or excessive exercising.
Medical workup
Measure height and weight, calculate body mass index, and check vital signs (including supine and standing blood pressure and pulse) and hydration status. Perform a neurologic exam, particularly for peripheral neuropathy, and check for cardiac, dermatologic, and GI complications (Tables 2 and 3). Include a dental examination if the patient admits or you suspect self-induced vomiting.
If treating eating disorders’ medical consequences is beyond the scope of your practice, refer the patient for evaluation by a physician with this experience.
Table 3
Common medical complications of binge eating disorder
| Obesity (body mass index>30) and related comorbidities: |
| Hypertension |
| Diabetes mellitus |
| Hyperlipidemia |
| Increased cardiovascular mortality |
| Obstructive sleep apnea |
| Degenerative arthritis |
| Gastroesophageal reflux symptoms and complications |
- Weight for height in women: 100 lbs for the first 5 feet, +5 lbs/inch over 5 feet
- Weight for height in men: 106 lbs for the first 5 feet, +6 lbs/inch over 5 feet.
For adolescents with suspected anorexia nervosa, estimate expected body weight from individual growth curves or standard growth charts posted on the Centers for Disease Control and Prevention Web site (see Related resources).
Note that the DSM-IV-TR weight criterion for anorexia of “less than 85% of expected” is an example, not an absolute cutoff. Anorexia nervosa would be an appropriate diagnosis for a patient who weighs more than 85% of expected weight but has lost substantial weight and meets the other diagnostic criteria.
BMI
Laboratory tests vary, depending on patients’ suspected eating disorders (Table 4). In 214 outpatient women with anorexia, the most common abnormalities were anemia (38.6%), leukocytopenia (34.4%), hyponatremia (19.7%) and hypokalemia (19.7%).17 With few exceptions, abnormal values are not predicted by the apparent degree of undernutrition.
Table 4
Laboratory studies for patients with suspected eating disorders
| For whom | Recommended tests |
|---|---|
| All eating disorder patients | Comprehensive metabolic panel (electrolytes, glucose, albumin, measures of hepatic and renal function), complete blood count, urinalysis, ECG, TSH |
| Add for patients with anorexia | Serum magnesium, phosphate, calcium; creatinine clearance; chest radiography; estrogen in women, testosterone in men; DEXA bone density scan; consider echocardiography, brain MRI; screen urine for unreported substances of abuse |
| Add for patients with bulimia and purging type anorexia | Serum magnesium, phosphate, calcium; DEXA scan if patient is amenorrheic or has history of anorexia; amylase (fractionated, if possible); consider fecal occult blood, urine for electrolytes and laxatives, urine drug screen |
| Add for patients with binge eating disorder | Fasting blood glucose, fasting lipid profile |
From diagnosis to treatment
Talking with patients. Discussing abnormal lab results with patients can be therapeutic. In our experience, recovered patients often report that worry about medical complications was their primary reason to seek treatment for eating disorders.
Relate the patient’s cognitive, mood, and physical symptoms to abnormal eating behavior, then present the eating disorder diagnosis as the beginning of treatment. For example, you could praise Mr. J for his courage in revealing his binge eating and tell him that identifying this problem is the first step toward solving it. Not only can he overcome binge eating, but treatment will also likely improve his mood, weight, and blood pressure.
Eating disorder patients who are medically stable, motivated for treatment, have good support, and are able and willing to come for frequent appointments are good candidates for outpatient eating disorder treatment.
For clinicians
- Standard growth charts. National Center for Health Statistics. Centers for Disease Control and Prevention. www.cdc.gov/growthcharts.
- Brewerton TD. Clinical handbook of eating disorders: an integrated approach. New York: Marcel Dekker; 2004.
- Work group on eating disorders. Practice guideline for the treatment of patients with eating disorders (2nd ed.). Washington, DC: American Psychiatric Publishing; 2000. Available at: http://www.psych.org/psych_pract/treatg/pg/eating_revisebook_index.cfm.
- Zerbe KJ. The body betrayed: a deeper understanding of women, eating disorders, and treatment. Carlsbad, CA: Gürze Books; 1995.
- National Eating Disorders Association. www.nationaleatingdisorders.org.
- National Association of Anorexia Nervosa and Associated Disorders. www.anad.org.
The internist next door asks you about his patient with bulimia, who routinely has potassium levels of 2.0 mEq/L. “She admits it’s a problem but thinks she’ll get fat if she stops purging. What can I tell her to get her into treatment?”
That afternoon, your longtime patient Mr. J—age 56 with depression, obesity, and hypertension—arrives for his appointment. With the day’s earlier conversation in mind, you ask him if he has an eating problem. Staring at the floor, he describes a lifelong battle with nighttime eating binges, which he has never mentioned to you before.
Mr. J may have concealed his binge eating because of shame or ambivalence about stopping a psychologically protective behavior. And his eating disorder may be complicating his depression treatment.
But outpatient psychiatrists can often manage patients like Mr. J in consultation with a nutritionist and primary care physician. Eating disorders are treatable,1,2 and many patients can recover. This article describes how to identify eating disorders so that treatment can begin.
Psychiatric comorbidity
Eating disorders are common in outpatient practice (Box)3,4 and coexist with a variety of psychiatric diagnoses (Table 1). For example, in 248 women with anorexia, bulimia, or unspecified eating disorders, 74% had another Axis I disorder, including:
- anxiety disorders (54%)
- affective disorders (52%)
- substance-related disorders (25%).
Eating disorders also are much more common in persons who present with psychiatric problems than in the general population. For example:
- Among 62 patients with a primary diagnosis of obsessive-compulsive disorder, 13% had anorexia or bulimia nervosa and another 18% met subthreshold criteria.6
- In 257 female patients with anxiety disorders, nearly 12% also met criteria for a possible eating disorder.7
Some 40% of persons with eating disorders meet DSM-IV-TR criteria for anorexia or bulimia nervosa. The other 60%—with eating disorder, not otherwise specified (ED-NOS)—are divided nearly evenly between binge eating disorder and subsyndromal anorexia or bulimia. Outpatient psychiatrists see these eating disorders most often.
Anorexia and bulimia nervosa prevalence rates are estimated to be 0.3% and 1%, respectively.3 But including ED-NOS patients increases the overall eating disorder prevalence to 2% to 3%—equal to or greater than the combined rates of schizophrenia and bipolar I disorder.
Although considered “subsyndromal,” ED-NOS patients suffer psychopathology, impairment, and medical comorbidity similar to those of persons who meet DSM-IV-TR criteria for anorexia or bulimia nervosa.4
Common psychiatric comorbidities in patients with eating disorders
| Disorder | Comorbidities |
|---|---|
| Anorexia and bulimia nervosa | Anxiety disorders (social phobia, PTSD, OCD) |
| Mood disorders (major depressive disorder, dysthymia, bipolar disorder) | |
| Substance use disorders (more common in patients who binge and/or purge) | |
| Personality disorders (cluster C more common in restricting anorexia, cluster B more common in patients who binge and purge) | |
| Binge eating disorder | Anxiety disorders (PTSD) |
| Mood disorders (major depressive disorder, bipolar disorder) | |
| PTSD: posttraumatic stress disorder | |
| OCD: obsessive-compulsive disorder | |
Who has eating disorders?
Most eating disorder patients are adolescent girls or young women with pronounced body image dissatisfaction. Other patients include:
Atypical young women. Some young women—usually Asian—meet most criteria for anorexia nervosa but lack the characteristic drive for thinness. They tend to have less psychopathology and better prognosis than typical female patients.9
Boys and men. Female-to-male ratios are approximately 11:1 for anorexia, 5:1 for bulimia, and 3:1 for binge eating disorder. Men and boys with eating disorders are similar to their female counterparts but are more likely to report:
- comorbid substance abuse
- having begun weight loss and purging in response to teasing or concerns about health, sports performance, or gay relationships, rather than appearance.10
Middle-aged to late-life. Midlife onset of eating disorders may be precipitated by losses or concerns about aging. In the elderly, eating disorders may be manifestations of complicated bereavement, and ruling out medical causes of weight loss is crucial in this age group.
Night-eating syndrome. Some patients eat at least 25% of daily calories after the evening meal. They experience insomnia, morning anorexia, and sometimes amnesia for the nocturnal eating episodes. Anxiety, depression, or sleep disorders may be contributing factors.12
Identifying eating disorders
Screening. No formal guidelines recommend which psychiatric patients to screen for eating disorders. We suggest screening any patients who are over- or underweight or have eating disorder risk factors, such as:
- young women (teens and early 20s)
- athletes in certain sports (gymnastics, ballet, figure skating, running, body building, wrestling)
- history of childhood sexual abuse.13
Interviewing. Evaluate all 4 illness domains—nutritional, medical, psychological, and social. Because patients often do not volunteer information, ask about:
- symptoms and complications
- onset and development of eating and weight problems
- history of being teased or criticized about weight
- weight history (premorbid, lowest, highest, and preferred weights).
DSM-IV-TR defines binging as consuming a large quantity of food in a discrete time and feeling out of control of eating. Ask specifically how the patient defines “binge,” and seek details of a typical binge. Also ask about compensatory behaviors (purging by vomiting or using laxatives or diuretics). Is the patient abusing ipecac, diet pills, or thyroid hormone? Does he or she fast or exercise compulsively (such as even while ill)?
Eating and exercise patterns. Ask the patient to recall everything eaten in the past 24 hours. This history can help estimate caloric intake and may reveal problematic eating patterns. For example, does the patient:
- avoid certain foods, consider others to be “safe,” or use diet products, gum, or mints?
- engage in food rituals, such as slow eating, hoarding food, or eating odd combinations?
- steal food, weigh him/herself frequently, or visit pro-anorexia/pro-bulimia Web sites?
Table 2
Potential medical complications of anorexia and bulimia nervosa
| Organ system | Symptoms | Signs, syndromes, laboratory abnormalities |
|---|---|---|
| Cardiovascular | Palpitations, dyspnea, chest pain, dizziness | Bradycardia, orthostasis, acrocyanosis |
| Prolonged PR and QTc intervals on ECG, mitral valve prolapse, cardiomyopathy in ipecac abusers | ||
| CNS | Anxious, depressed, or irritable mood; obsessiveness; cognitive deficits; seizures (rare) | Enlarged ventricles on CT or MRI, deficits on neuropsychological testing, abnormal EEG, signs of peripheral neuropathy |
| Dermatologic | Hair loss, dry skin | Xerosis, carotenoderma, cheilitis, lanugo, brittle hair and nails, Russell’s sign (callus on dorsum of hand used to induce vomiting) |
| Endocrine | Fatigue, cold intolerance | Hypothermia, hypoglycemia, hypercortisolemia, ↓ T3 and T4 |
| Gastrointestinal | Bloating, constipation, spontaneous vomiting, reflux, abdominal pain, heartburn, hematemesis | Abnormal bowel sounds, delayed gastric emptying, superior mesenteric artery syndrome, pancreatitis |
| In patients who vomit: Mallory-Weiss tears, Barrett’s esophagus, occult blood in stool, ↑ amylase, gingivitis, dental caries, sialadenosis, perimolysis | ||
| Genitourinary | Polyuria, oliguria | ↑ BUN, nephrolithiasis, hypokalemic nephropathy, renal failure (rare). |
| Hematologic | Fatigue, bruising | Anemia; ↓ numbers of WBCs, RBCs and platelets; ↓ ferritin, B12, folate |
| Metabolic | Weakness, cardiac or CNS manifestations | ↓ K, Na, Mg, phosphate; ↑ cholesterol; metabolic alkalosis (from vomiting), or acidosis (from laxatives); thiamin and niacin deficiencies (rare). |
| Musculoskeletal | Weakness, cramps, bone pain | Wasting, ↑ CK (rare), decreased bone mineral density, pathologic fractures |
| Reproductive | Amenorrhea, ↓ libido, infertility, ↑ pregnancy, neonatal complications | Arrested sexual development; ↓ estrogen or testosterone; prepubertal levels of LH and FSH |
Interview adjuncts
Assessment tools. In addition to patient interviews, some clinicians use self-report scales to screen for eating disorders or to monitor treatment. Reliable and valid self-report questionnaires include the Eating Disorder Examination-Q (36 items),14 Eating Disorder Inventory (91 items),15 and Eating Attitudes Test (26 items).16
The Eating Attitudes Test takes 10 minutes to complete and is widely used for screening. A cut-off score of 20 indicates a potential eating disorder and the need for a follow-up interview.
Self-report diaries can help identify binge eating triggers—usually dietary restriction combined with interpersonal stressors. Ask the patient to record all meals, snacks, binges, purges, and exercise activities, plus time of day and associated feelings, thoughts, and situations. Diaries can also reveal maladaptive thoughts, such as body image distortion, and problematic coping strategies, such as purging or excessive exercising.
Medical workup
Measure height and weight, calculate body mass index, and check vital signs (including supine and standing blood pressure and pulse) and hydration status. Perform a neurologic exam, particularly for peripheral neuropathy, and check for cardiac, dermatologic, and GI complications (Tables 2 and 3). Include a dental examination if the patient admits or you suspect self-induced vomiting.
If treating eating disorders’ medical consequences is beyond the scope of your practice, refer the patient for evaluation by a physician with this experience.
Table 3
Common medical complications of binge eating disorder
| Obesity (body mass index>30) and related comorbidities: |
| Hypertension |
| Diabetes mellitus |
| Hyperlipidemia |
| Increased cardiovascular mortality |
| Obstructive sleep apnea |
| Degenerative arthritis |
| Gastroesophageal reflux symptoms and complications |
- Weight for height in women: 100 lbs for the first 5 feet, +5 lbs/inch over 5 feet
- Weight for height in men: 106 lbs for the first 5 feet, +6 lbs/inch over 5 feet.
For adolescents with suspected anorexia nervosa, estimate expected body weight from individual growth curves or standard growth charts posted on the Centers for Disease Control and Prevention Web site (see Related resources).
Note that the DSM-IV-TR weight criterion for anorexia of “less than 85% of expected” is an example, not an absolute cutoff. Anorexia nervosa would be an appropriate diagnosis for a patient who weighs more than 85% of expected weight but has lost substantial weight and meets the other diagnostic criteria.
BMI
Laboratory tests vary, depending on patients’ suspected eating disorders (Table 4). In 214 outpatient women with anorexia, the most common abnormalities were anemia (38.6%), leukocytopenia (34.4%), hyponatremia (19.7%) and hypokalemia (19.7%).17 With few exceptions, abnormal values are not predicted by the apparent degree of undernutrition.
Table 4
Laboratory studies for patients with suspected eating disorders
| For whom | Recommended tests |
|---|---|
| All eating disorder patients | Comprehensive metabolic panel (electrolytes, glucose, albumin, measures of hepatic and renal function), complete blood count, urinalysis, ECG, TSH |
| Add for patients with anorexia | Serum magnesium, phosphate, calcium; creatinine clearance; chest radiography; estrogen in women, testosterone in men; DEXA bone density scan; consider echocardiography, brain MRI; screen urine for unreported substances of abuse |
| Add for patients with bulimia and purging type anorexia | Serum magnesium, phosphate, calcium; DEXA scan if patient is amenorrheic or has history of anorexia; amylase (fractionated, if possible); consider fecal occult blood, urine for electrolytes and laxatives, urine drug screen |
| Add for patients with binge eating disorder | Fasting blood glucose, fasting lipid profile |
From diagnosis to treatment
Talking with patients. Discussing abnormal lab results with patients can be therapeutic. In our experience, recovered patients often report that worry about medical complications was their primary reason to seek treatment for eating disorders.
Relate the patient’s cognitive, mood, and physical symptoms to abnormal eating behavior, then present the eating disorder diagnosis as the beginning of treatment. For example, you could praise Mr. J for his courage in revealing his binge eating and tell him that identifying this problem is the first step toward solving it. Not only can he overcome binge eating, but treatment will also likely improve his mood, weight, and blood pressure.
Eating disorder patients who are medically stable, motivated for treatment, have good support, and are able and willing to come for frequent appointments are good candidates for outpatient eating disorder treatment.
For clinicians
- Standard growth charts. National Center for Health Statistics. Centers for Disease Control and Prevention. www.cdc.gov/growthcharts.
- Brewerton TD. Clinical handbook of eating disorders: an integrated approach. New York: Marcel Dekker; 2004.
- Work group on eating disorders. Practice guideline for the treatment of patients with eating disorders (2nd ed.). Washington, DC: American Psychiatric Publishing; 2000. Available at: http://www.psych.org/psych_pract/treatg/pg/eating_revisebook_index.cfm.
- Zerbe KJ. The body betrayed: a deeper understanding of women, eating disorders, and treatment. Carlsbad, CA: Gürze Books; 1995.
- National Eating Disorders Association. www.nationaleatingdisorders.org.
- National Association of Anorexia Nervosa and Associated Disorders. www.anad.org.
1. Reas Dl, Williamson DA, Martin CK, Zucker NL. Duration of illness predicts outcome for bulimia nervosa: a long-term outcome study. Int J Eat Disord 2000;27:428-34.
2. Nielsen S, Moller-Madsen S, Isager T, et al. Standardized mortality in eating disorders—a quantitative summary of previously published and new evidence. J Psychosom Res 1998;44:413-34.
3. Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord 2003;34(4):383-96.
4. Watson TL, Andersen AE. A critical examination of the amenorrhea and weight criteria for diagnosing anorexia nervosa. Acta Psychiatr Scand 2003;108:175-82.
5. Milos G, Spindler A, Schnyder U. Psychiatric comorbidity and eating disorder inventory (EDI) profiles in eating disorder patients. Can J Psychiatry 2004;49:179-84.
6. Rubenstein CS, Pigott TA, L’ Heureux F, et al. A preliminary investigation of the lifetime prevalence of anorexia and bulimia nervosa in patients with obsessive compulsive disorder. J Clin Psychiatry 1992;53(9):309-14.
7. Becker CB, DeViva JC, Zayfert C. Eating disorder symptoms among female anxiety disorder patients in clinical practice: the importance of anxiety comorbidity assessment. J Anxiety Disord 2004;18(3):255-74.
8. Keys A, Brozek J, Henschel A, et al. The biology of human starvation. Minneapolis: University of Minnesota Press; 1950.
9. Ramacciotti CE, Dell’Osso L, Paoli RA, et al. Characteristics of eating disorder patients without a drive for thinness. Int J Eat Disord 2002;32:206-12.
10. Andersen AE. Males with eating disorders: medical considerations. In: Mehler PS, Andersen AE (eds). Eating disorders: a guide to medical care and complications. Baltimore: The Johns Hopkins University Press; 1999;214-26.
11. Lantzouni E, Frank GR, Golden NH, Shenker RI. Reversibility of growth stunting in early onset anorexia nervosa: a prospective study. J Adolesc Health 2002;31(2):162-5.
12. Napolitano MA, Head S, Babyak MA, Blumenthal JA. Binge eating disorder and night eating syndrome: psychological and behavioral characteristics. Int J Eating Disord 2001;30:193-203.
13. Jacobi C, Morris L, de Zwaan M. Overview of risk factors for anorexia nervosa, bulimia nervosa, and binge eating disorder. In: Brewerton, TD (ed). Clinical handbook of eating disorders: An integrated approach. New York: Marcel Dekker; 2004;183-208.
14. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire. Int J Eating Disord 1994;16:363-70.
15. Garner DM. Eating Disorder Inventory-2 professional manual. Odessa, FL: Psychological Assessment Resources; 1991.
16. Garner DM. Psychoeducational principles in treatment. In: Garner DM, Garfinkel PE (eds). Handbook of treatment for eating disorders (2nd ed). New York: Guilford Press; 1997;145-77.
17. Miller KK, Grinspoon SK, Ciampa J, et al. Medical findings in outpatients with anorexia nervosa. Arch Intern Med 2005;165(5):561-6.
1. Reas Dl, Williamson DA, Martin CK, Zucker NL. Duration of illness predicts outcome for bulimia nervosa: a long-term outcome study. Int J Eat Disord 2000;27:428-34.
2. Nielsen S, Moller-Madsen S, Isager T, et al. Standardized mortality in eating disorders—a quantitative summary of previously published and new evidence. J Psychosom Res 1998;44:413-34.
3. Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord 2003;34(4):383-96.
4. Watson TL, Andersen AE. A critical examination of the amenorrhea and weight criteria for diagnosing anorexia nervosa. Acta Psychiatr Scand 2003;108:175-82.
5. Milos G, Spindler A, Schnyder U. Psychiatric comorbidity and eating disorder inventory (EDI) profiles in eating disorder patients. Can J Psychiatry 2004;49:179-84.
6. Rubenstein CS, Pigott TA, L’ Heureux F, et al. A preliminary investigation of the lifetime prevalence of anorexia and bulimia nervosa in patients with obsessive compulsive disorder. J Clin Psychiatry 1992;53(9):309-14.
7. Becker CB, DeViva JC, Zayfert C. Eating disorder symptoms among female anxiety disorder patients in clinical practice: the importance of anxiety comorbidity assessment. J Anxiety Disord 2004;18(3):255-74.
8. Keys A, Brozek J, Henschel A, et al. The biology of human starvation. Minneapolis: University of Minnesota Press; 1950.
9. Ramacciotti CE, Dell’Osso L, Paoli RA, et al. Characteristics of eating disorder patients without a drive for thinness. Int J Eat Disord 2002;32:206-12.
10. Andersen AE. Males with eating disorders: medical considerations. In: Mehler PS, Andersen AE (eds). Eating disorders: a guide to medical care and complications. Baltimore: The Johns Hopkins University Press; 1999;214-26.
11. Lantzouni E, Frank GR, Golden NH, Shenker RI. Reversibility of growth stunting in early onset anorexia nervosa: a prospective study. J Adolesc Health 2002;31(2):162-5.
12. Napolitano MA, Head S, Babyak MA, Blumenthal JA. Binge eating disorder and night eating syndrome: psychological and behavioral characteristics. Int J Eating Disord 2001;30:193-203.
13. Jacobi C, Morris L, de Zwaan M. Overview of risk factors for anorexia nervosa, bulimia nervosa, and binge eating disorder. In: Brewerton, TD (ed). Clinical handbook of eating disorders: An integrated approach. New York: Marcel Dekker; 2004;183-208.
14. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire. Int J Eating Disord 1994;16:363-70.
15. Garner DM. Eating Disorder Inventory-2 professional manual. Odessa, FL: Psychological Assessment Resources; 1991.
16. Garner DM. Psychoeducational principles in treatment. In: Garner DM, Garfinkel PE (eds). Handbook of treatment for eating disorders (2nd ed). New York: Guilford Press; 1997;145-77.
17. Miller KK, Grinspoon SK, Ciampa J, et al. Medical findings in outpatients with anorexia nervosa. Arch Intern Med 2005;165(5):561-6.