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Binge Eating Disorder and the DSM-5: What the Changes Mean

Internal Publication: River Centre Clinic (2014)

DSM-5 (the newest edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association) introduces important changes in the diagnostic system for eating disorders that improves the ability for clinicians to arrive at an accurate diagnosis and will hopefully lead to better reimbursement from insurers. Perhaps the most significant improvement with the DSM-5 is that Binge Eating Disorder (BED) has been moved from the obscurity of an appendix in the DSM-IV to being designated in the DSM-5 as a full-fledged diagnosis that parallels the other main eating disorders of Anorexia Nervosa (AN) and Bulimia Nervosa (BN). In the DSM-IV, BED was given the ignominious lack of distinction as an Eating Disorder Not Otherwise Specified (EDNOS) which, by its very title, made it seem to be of less clinical concern than AN or BN. Although unintended, the use of the EDNOS diagnosis had the effect of minimizing the seriousness of BED, and in some cases led to third party payers balking at reimbursement. In reality, the psychological distress and potential medical consequences of BED can be formidable and delaying or denying treatment to those with this diagnosis is a matter of serious clinical concern.

According to a national survey by Swanson et al. (2011), BED is the most common eating disorder in the United States affecting 3.5% of adult women and 2% of adult men and up to 1.6% of adolescents. It is most common in women in early adulthood but it is more common in men at midlife. It appears that BED affects blacks and whites equally and is associated with significant physical and psychiatric conditions. Compared with normal weight or obese control groups, people with BED have higher levels of anxiety and both current and lifetime major depression. Although most people with obesity do not have BED, up to two-thirds of people with BED are obese and can have the medical difficulties associated with this condition. Therefore, elevating BED to the status as a formal eating disorder should have a huge impact because of its high prevalence in the general population as well as the different gender and racial demographics it encompasses. Inclusion of BED as a full-fledged diagnosis will also help to correct the public misperception that eating disorders are either uncommon or even trivial by being restricted to a narrow segment of the population. Hopefully, the changes introduced by the DSM-5 will also open up the study of eating disorders to men and minorities.

What are the key diagnostic features of BED according to the DSM-5? They are:

  1. Recurrent episodes of binge eating that is defined as an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances accompanied by a sense of lack of control over eating during the episode (These features are important because they distinguish BED from simple overeating).
  2. Binge eating episodes are associated with three (or more) of the following:
    1. Eating much more rapidly than normal
    2. Eating until feeling uncomfortably full
    3. Eating large amounts of food when not feeling physically hungry
    4. Eating alone because of being embarrassed by how much one is eating
    5. Feeling disgusted with oneself, depressed, or very guilty after overeating
  3. Marked distress regarding binge eating is present.
  4. The binge eating occurs, on average, at least once a week for three months.
  5. Absence of regular compensatory behaviors (such as purging) and does not occur exclusively during the course Bulimia Nervosa or Anorexia Nervosa.

An important change in the new DSM-5 diagnostic criteria for BED is reducing the frequency of binge episodes from 2 times per week for 6 months required by the DSM-VI-R to the DSM-5 standard of an average of one episode weekly for 3 months. Lowering the threshold for binge eating episodes has important public policy implications to the extent that reimbursement for treatment is contingent on receiving a formal eating disorder diagnosis. Hopefully, this change will allow sufferers to receive interventions earlier in the course of the disorder. Perhaps the most important implication of the changes in the diagnostic status of BED is that it will likely result in increasing research on effective treatments. Currently, there is evidence for the effectiveness of both outpatient Cognitive Behavioral Therapy and Interpersonal Therapy. There also have been studies showing that certain psychotropic medications can be helpful in ameliorating symptoms. Nevertheless, there is the need for further research and the new DSM-5 should provide an impetus for improved understanding of BED, better access to treatments and advancements in the quality of treatment available.

Recommended Readings:
Hilbert, A. Bishop ME, Stein, RI, Tanofsky-Kraff, M, Swenson, AK, Welch, RR, et al. (2012). “Long-term efficacy of psychological treatments for binge eating disorder.” British Journal of Psychiatry 200(3): 232-237.
Keel PK, Mayer SA, Harnden-Fischer JH (2001). Importance of size in defining binge eating episodes in bulimia nervosa. International Journal of Eating Disorders2001, 29:294–301.
Mond JM, Hay PJ, Rodgers B, Owen C: Comparing the health burden of overweight and eating-disordered behavior in young adult women. J Women’s Health 2009, 18:1081–1089.
Mond JM, Hay PJ, Rodgers B, Owen C, Crosby R, Mitchell JE: Use of extreme weight control behaviors with and without binge eating in a community sample of women: Implications for the classification of bulimic-type eating disorders. Int J Eat Disord 2006, 39:294–302.
Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas KR. Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry. 2011;68(7):714–723.

Contributed by:
David M. Garner, Ph.D., Founder and Administrative Director, River Centre Clinic (RCC)
Julie Desai, M.A., Director, Adult Partial Hospitalization Program, RCC
Meggan Desmond, LISW, Director, Adolescent Residential Program, RCC

Note: The River Centre Clinic has just opened a new IOP specifically dedicated to BED indicating that the new criteria have resulted in improved treatment options for this eating disorder at our treatment facility. Intensive Outpatient Program (IOP) for Binge Eating Disorder

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The Effects of Starvation on Behavior: Implications for Dieting and Eating Disorders

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