It is the commonest eating disorder while at the same time the least known: binge-eating disorder. About two to three percent of adults suffer from it: they repeatedly have binge bouts, in which they lose control of their eating, eating hastily and devouring huge amounts of food. Very often the patients suffer from other mental health problems such as depression, fears, sleep disorders or abuse of alcohol or other substances.
“In contrast to patients with bulimia, binge eaters do not undertake countermeasures, such as vomiting, laxatives or excessive exercise”, says Henrike Pierchalla, psychologist at Therapienetz Essstörung [Therapy Network for Eating Disorder] in Munich. People with binge-eating disorder are therefore often overweight. This can lead to significant health problems: frequent consequences include type 2 diabetes, high blood pressure, cardiovascular diseases and disorders of the musculoskeletal and postural systems.
For a long time binge-eating was not listed in the international classification systems as a distinct disorder. The condition was therefore often overlooked and not properly treated. Meanwhile, it has increasingly come to be recognised as a distinct disorder: In DSM-V binge-eating disorder has since 2013 been included as a separate disease, the next version of the International Classification of Diseases (ICD), ICD-11, should follow suit in 2018.
Food for relaxation or as a consolation
Sufferers use binge eating to cope with negative feelings and problems which they otherwise cannot overcome. “The food serves as a distraction or as tension release, or satisfies needs that cannot otherwise be satisfied – it delivers for instance reassurance and comfort”, says Pierchalla. The triggers for binge eating are often stress, anger, sadness or boredom. Afterwards binge-eaters however experience shame and guilt, disgust and self-blame. Many try to conceal the binges from those in their environment – even from close friends and family members.
According to the DSM-V definition, the binges need to occur on at least two days a week over a period of at least six months. In addition, eating behaviour is also dysfunctional between binge eating attacks: sufferers eat irregularly and switch between heavily controlled and uncontrolled eating.
Typically, binge eating-disorder begins between 20 and 35 years of age. It often also first develops between 45 and 55 years of age. About two thirds of those affected are women, one third are men. Therefore the proportion of men is significantly higher than with anorexia or bulimia.
Obesity: physicians should bear in mind the possibility of an eating disorder
Binge-eating does indeed affect overweight people more frequently than those in the general population – about four to nine percent, to be specific. Nevertheless, it’s far from true that all obese people have a tendency to binge eat. “Therefore, a careful evaluation is very important”, stresses Pierchalla. People who binge-eat often first turn to their GP – or are touched upon by the GP due to the patient’s obesity. “Whichever the case, most doctors primarily consider the physical consequences of obesity and advise their patients to reduce their weight”, says Pierchalla. “Many do not consider that an eating disorder might be behind the problem”. And since the patients are ashamed of their binge eating, they often do not mention this in connection to themselves.
“It would be useful if doctors would at least ask one or two screening questions – especially whether large amounts of food are being eaten in one sitting”, says the psychologist. “This is because if the eating disorder is not detected and not treated, it is difficult to get the long-term obesity under control”. The doctor can then give the addresses of counselling centres or psychotherapists to those afflicted. “As part of the first step it can be ascertained in more detail whether a binge-eating disorder exists”, says Pierchalla.
Difficulties with decisions
Where the tendency to eat excessively comes from is thus far not known. It is assumed to be a combination of factors: psychological aspects, especially difficulties in dealing with feelings; dietary factors as well, such as a prior history of obesity and dieting, can trigger binge eating. Stressful life circumstances also often play a role. There is moreover also evidence of biological factors such as a certain genetic predisposition and changes in brain metabolism.
A study by the Max Planck Institute for Human Cognitive and Brain Sciences in Leipzig (Germany) recently showed that such people also have decision making problems when dealing with everyday things – and that this is reflected in brain activity. The subjects in the study participated in a card game in which they had to flexibly adapt their decision making to new conditions. “Binge-eating patients constantly tested out the obviously inferior option, although they had previously learned something else”, explains Andrea Reiter, the lead author of the study.
At the same time, in these patients brain regions which play a role in targeted decisions, or are normally active in the instance of errors (thus contributing to making favourable decisions), were less active. Apparently binge-eating patients generally make unfavourable decisions and do not manage to flexibly adapt their behaviour to new situations, the authors conclude – similarly to how they understand the negative consequences of binge eating and yet do not manage to stop them.
Eating regularly and dealing differently with feelings
A diversity of approaches can be used, depending on how strongly pronounced the eating disorder is. “With less severe cases it is often sufficient if those affected participate in dietary advice sessions, exercise more and possibly join a support group”, says Pierchalla. Sufferers are however often very emotionally charged. Outpatient psychotherapy is then the treatment of choice. “In the instance of strongly pronounced binge-eating, marked obesity or major depression, temporary hospitalisation might be useful”, says the psychologist.
Turning to psychotherapy: cognitive behavioural therapy and interpersonal therapy have proven effective. The approach is similar to that for bulimia. In some cases the use of antidepressants would be supportive, especially selective serotonin reuptake inhibitors (SSRI). These can contribute to reducing the binge eating bouts.
The aim of psychotherapy is normalisation of eating behaviour. “Patients learn how irregular eating or temporarily fasting leads to cravings, and they gradually learn to eat regularly”, explains Pierchalla. They also maintain eating protocols and learn to recognise the triggers of their binges and to deal with problems and negative feelings differently.
“In the case of one female patient, the binges for instance often occurred on Wednesday evening”, reports the expert. “It then occurred to her that it was usually after a team meeting, which she found extremely stressful. In this case one can specifically look at what one can do to better cope with stress”.