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Thursday
Nov032011

Binge Eating Disorder and Night Eating Syndrome

Quick Recap

First I will quote myself from Why is Bingeing not Bingeing when You are Recovering from Restricted Eating? to recap some of what we know thus far when it comes to BED and NES: 

“One researcher at the forefront of these distinct conditions unrelated to the REDS is Albert Stunkard. Stunkard is suggesting through his research that binge eating disorder (BED) not only is rare, but also is likely a marker of other psychopathological disorders and not a distinct disorder in and of itself.

Unfortunately both BED and night eating syndrome (NES) are being identified and diagnostically defined so far through the observation of measurable symptoms and self-reported questionnaire responses rather than determining what, if any, neuroendocrine genotypes may underpin these unrelated conditions.

Both are defined in the appendices of the DSM-IV but must be classified as ED-NOS (eating disorder not otherwise specified) for the purpose of diagnosing patients at present.

Stunkard may be on the right track but rather than being markers of psychopathology, both BED and particularly NES may actually be markers for endocrine disorders.

The field of chronobiology has identified that NES may indeed be a sleep disorder. Fat tissue acts as an endocrine (hormone) organ that in turn acts on circadian rhythms and metabolism.

Controlled studies also suggest that people with diagnosed sleep disorders of narcolepsy or cataplexy have higher than anticipated rates of binge eating.

NES and BED are far more prevalent in the obese rather than non-obese populations.

There are specific melanocortin-4 receptor gene variants (MCR4) in patients with BED. MCR-4 mediates the central nervous system’s response to leptin (a critical gating hormone associated with appetite, metabolism, bone formation and reproductive hormone function). Genetic variants near MCR-4 are also associated with insulin resistance and obesity as well.”

So these are some of the biological underpinnings (some controversial at this point) that we believe may need to be present to create the scaffolding or structure that must be there before BED or NES could even be considered feasible diagnoses.

Night Eating Syndrome

First let’s dispense with the more straightforward and less contentious eating disorder classification of NES. In point of fact, it has a growing body of data that are in agreement that its origins reside in circadian rhythm skews. Initial studies show NES patients respond well to full spectrum light therapy, as is used for patients diagnosed with seasonal affective disorder. NES is also something that flares during stressful periods and is alleviated with the resolution of stressful stimuli. NES patients also respond well to stress alleviation efforts such as meditation and mindfulness practices. 

The typical behavioral characteristics of the night eating syndrome have been described as morning anorexia, evening hyperphagia and insomnia. The neuroendocrine characteristics have been described as changes in the circadian rhythm by an attenuation in the nocturnal rise of the plasma concentrations of melatonin and leptin and an increased circadian secretion of cortisol. The night eaters also have an overexpressed hypothalamic-pituitary-adrenal axis with an attenuated response to stress.”

 [Grethe Stoa Birketvedt and Jon R. Florholmen, taken from Sleep and Sleep Disorders: 
A Neuropsychopharmacological Approach, King’s College, London, 2006]

Can a patient be both on the restrictive eating disorder spectrum and have night eating syndrome? Not very likely. The nature of the “morning anorexia” experienced by those with NES is not driven by efforts to restrict that subsequently fail by the end of the day with reactive eating sessions.

First of all, NES generally requires a BMI of at least 30. Secondly, food intake is not in “binge” quantity (which is not common for those on the REDS who are attempting to restrict throughout the day and exhaust the suppression of hunger by the end of the day). An NES patient snacks on about 271 calories at a time [Stunkard, 2008].

Generally speaking, there is much less contention among the experts about NES being a distinct neuroendocrine-based eating disorder that should have a distinct classification within the DSM. 

The same cannot be said of binge eating disorder (BED).

The Clinical Distinctions Between

the Restrictive Eating Disorder Spectrum and Binge Eating Disorder

A serious complication with the classification of BED is the possibility that someone with restrict/reactive eating cycles is misdiagnosed with a binge eating disorder. The possibility of misdiagnosis is high due to confusing symptom lists used for BED.

Here are the critical features that delineate BED from the far more common restrictive eating disorder spectrum:

  1. The patient eats “higher than normal” amounts of food in secret in early childhood. These episodes were more frequent than, as an example, the odd childhood birthday or Halloween mishap. They pre-date any effort to go on a diet or restrict calories.
  2. The patient was overweight by age nine and “clinically obese” by age 11.
  3. During their tween/teen years the patient was placed on one or more restrictive calorie diets by doctors and/or parents.
  4. The patient does not practice any restrictive behaviors of his or her own volition, and when placed on diets as a child, simply undermined them as best as he or she could. 

The BED patient may also share in common with many individuals on the REDS spectrum, an intense hatred of his or her body shape irrespective of the actual body weight and body shape he or she has. 

Problematically the symptom list in Appendix B of the DSM-IV that identifies BED has items 1 through 4 essentially indistinguishable from restriction/reactive eating cycles that form part of the restriction eating disorder spectrum.

In both a cultural atmosphere and a research funding focus that prefer to view the presence of fat as a disease, I reserve judgment when it comes to the diagnostic validity of BED. 

BED Misdiagnosis

Those who express BED, as it is currently defined in Appendix B of the DSM-IV, rarely present with bingeing behaviors in isolation. 

Most have co-morbid presentations of a wide variety of so-called mental conditions: obsessive-compulsive behaviors (often sub-type compulsivity/hoarding), body dysmorphic disorder, major depressive disorder, anxiety disorders, bi-polar type I disorder, and/or borderline personality disorder.

Now whenever such a mish-mash of so-called mental disorders presents in a single patient, then I get very curious about what might be the actual underpinning those neural expressions. 

I am going to quote from an on-line support site dedicated to binge eating disorder that will remain nameless:

And it’s hard to define a condition when there are no obvious physical signs or symptoms. While many binge eaters are overweight or obese, not all of them are. And not all persons who are obese are binge eaters, although some of them are.

Most experts agree, though, that binge eaters share these behavioral and emotional signs and symptoms:

  1.  Eating excessively large amounts of food
  2.  Eating quickly during a binge
  3.  Eating food even when not hungry
  4.  Frequently eating alone out of embarrassment over the quantity of food eaten
  5.  Hiding or hoarding food
  6.  Hiding evidence of eating (wrappers, containers)
  7.  Feeling out of control in regard to eating
  8.  Feeling disgusted or guilty about binges
  9.  Dieting or food restriction after binge episodes, usually without weight loss
  10.  Depression or anxiety

So can any of you spot any distinguishing symptom in that list that would categorically rule out cycles of restriction and reactive eating or non-purging sub-type bulimia nervosa?

In fact, the above list is indeed a list of symptoms commonly experienced during reactive eating cycles associated with the REDS, however the originators of the site are likely not aware of that.

And a patient with restrictive eating behaviors who is misdiagnosed with BED using the above symptom list is going to have his or her recovery greatly impeded as a result.

Thankfully there are some wily researchers out there with the rubber gloves on trying to get the BED symptom rat’s nest cleaned up and clarified.

Qualitative and Quantitative

Distinguishability of Eating Disorders

Donald Williamson, of the Pennington Biomedical Research Center in Louisiana, and his colleagues took some 201 subjects with various eating disorder diagnoses and matched them with 24 obese non-eating-disordered controls and a further 116 normal weight comparison controls.

They published their findings in the March 2002 edition of the American Journal of Psychiatry.

Specifically, they were looking to determine whether there were any discreet emotional facets of anorexia nervosa, bulimia nervosa and binge eating disorder that distinguish one from the other and also distinguish them from ‘normalcy’.

The primary aims of this study were to 1) identify latent features of eating disorder symptoms as defined by the DSM-IV descriptions of anorexia nervosa, bulimia nervosa, and binge eating disorder; 2) compare the three eating disorder groups with comparison groups on the features of eating disorder symptoms identified by using factor analysis; and 3) examine whether the eating disorder features occur on a continuum with normalcy or constitute discrete classes or categories.”

 [D. Williamson et al., 2002]

And here’s what they found:

“Eating disorder groups differed on one or more of the dimensions. The bulimia nervosa group scored high on the features of binge eating and fear of fatness/compensatory behaviors but not on drive for thinness. The binge eating disorder group scored high on binge eating but not on the other two features. The binge eating disorder group differed from the obese comparison group on the binge eating feature, which suggests that the severity of binge eating may be a meaningful distinction between these two groups. The anorexia nervosa group scored high on fear of fatness/compensatory behaviors and drive for thinness but not on binge eating. The group with eating disorder not otherwise specified was intermediate to the full syndromes of anorexia nervosa and bulimia nervosa on binge eating and drive for thinness but was equivalent on fear of fatness/compensatory behaviors. These findings support the view that the symptoms of eating disorder not otherwise specified are similar to but less severe than those of the full syndromes of anorexia and bulimia nervosa.”

 [ibid.]

Now, with disclaimers that this study has a relatively small sample size and further follow-up study is indicated, what do the results actually suggest?

  1. There are three primary and distinct features for clinical levels of eating disorders: a) binge eating b) fear of fat/compensatory behaviors and c) drive for thinness.
  2. Fear of fat/compensatory behaviors and drive for thinness are not present for those with clinical BED.

What Williamson and his colleagues have done is to use applied mathematics to try to determine whether phenotypic indicator correlations (meaning observable traits or characteristics that appear together) are categories of the condition under investigation (taxonic) or are just dimensions or factors of that condition (nontaxonic). 

Taxometric investigation of psychopathologies is a way to try to tease apart the symptom lists in something like the DSM-IV to determine what is perhaps more or less relevant for definitive diagnosis.

Now we’re still just looking at observable traits and whether they do or do not appear together and what we might be able to ascertain from those correlations, but it’s a good start.

Complementary taxometric studies undertaken by David Gleaves and colleagues have further confirmed that there are one or more latent discontinuities particularly associated with binge eating [DH Gleaves et al., 2000, 2002, 2004 and 2007]

Naturally, there’s some equally valid research data out there to suggest that eating disorders exist on a continuum even when applying taxometric assessments. The rat’s nest is far from cleaned up at this point. 

Suffice to say that the bickering continues regarding the nosological (classification of disease) status of BED.

And, as is pointed out in the Oxford Handbook of Eating Disorders:

“…the way that eating disorders are classified by the DSM has a significant impact on empirical research and treatment development.”

 And it goes on to explain exactly why the DSM classifications are problematic:

 “ …they [researchers] do not allow themselves to contest currently accepted conventions: therefore, the evolution of new valid diagnostic criteria, and associated etiological and treatment implications, is disrupted.”

[W. Stewart Agras (ed.), The Oxford Handbook of Eating Disorders, Oxford University Press, 2010, p. 17]

And This Means What Exactly?

At the moment a good comparator to receiving a BED diagnosis might be to think of it as irritable bowel syndrome (IBS).

Irritable bowel syndrome is not a diagnosis of illness or disease. It is the recognition of identifiable symptoms in the absence of any identifiable cause. IBS is a pro-symptomatic, anti-diagnostic place-holder. And while only 8% of experts (meaning gastroenterology specialists) surveyed will agree that IBS is a diagnosis of exclusion, 72% of primary care physicians believe it to be a diagnosis of exclusion [B.M.R. Spiegel et al., 2010]. 

Who’s right, the GPs or the experts? Probably the GPs in this case: 

A confidential draft document leaked from a medical communications company, In Vivo Communications, describes a three year “medical education programme” to create a new perception of irritable bowel syndrome as a “credible, common and concrete disease.” The proposed 2001-3 education programme is part of the marketing strategy for GlaxoSmithKline's drug Lotronex (alosetron hydrochloride).”

[R. Moynihan et al., 2002]

In order to receive the IBS place-holder, any other possible cause for the symptoms must first be ruled out: any inflammatory bowel disease, parasitic infection, cancer, non-IgE-mediated food reactions… 

Now, in reality many receive the IBS place-holder without the exhaustive efforts to rule out the presence of disease. And we can see this trend is increasing due to the close relationships that medical experts have with drug companies and how that subsequently shapes the diagnostic criteria over time.

If you have been given a diagnosis of BED, then be suspicious and consider that further investigation with other professionals will be a good course of action to take.

Let’s Say the BED Stands, Then What?

It is highly likely that the binge eating, while distressing to you, will not be the focus of successful therapy and recovery for you.

Because there is a high likelihood that another condition may be responsible for the bingeing symptoms, recovery is best achieved working with a clinical psychologist who offers both cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT).

For the restrictive eating disorder spectrum, a critical feature of full recovery is to undergo CBT and in that case the provider does not need to be a clinical psychologist – an accredited counselor or therapist is suitable (and often even preferable).

For BED, having a clinical psychologist ensures that he or she can identify and incorporate any other conditions that may either co-exist with the bingeing, or contribute to the behavior, or perhaps be the cause of the behavior.

For the restrictive eating disorder spectrum, if all the therapeutic focus is laser-beamed onto the replacement of restrictive behaviors with non-restrictive ones, then recovery is fully supported for the vast majority of patients with this spectrum disorder. In fact, many accompanying symptoms (anxiety, compulsivity, paranoia) are the result of the underlying eating disorder and not in fact co-morbid conditions.

For BED, the therapeutic focus is one of investigation followed by a treatment plan that is designed specifically for you.

And remember, if you are practicing restrictive behaviors of any kind on either a periodic intermittent basis or a fairly regular basis (excessively exercising, purging, abusing laxatives, dieting, watching percentages or macronutrient intake, adhering to “healthy” food intake at all costs), then no matter the conviction of the health care provider who diagnosed you with BED, it is not BED:

“The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa.”

[Binge Eating Disorder Criterion E, Appendix B, DSM-IV]

Recover from BED

The recovery process from BED does not differ appreciably from that of the REDS.

Dieting and calorie restriction is universally a health-damaging and an ultimately unsustainable practice, whether you have been diagnosed with one of the various eating disorders or whether you are genetically protected from disordered eating but are nonetheless impacted by society’s anxiety about fatness.

Our bodies are very well conditioned to take on excess fat and very poorly designed to be underweight at all. The best way to stabilize weight and metabolic rates is to stop restricting calories at all.

If you have tremendous self-loathing when it comes to your body shape and cannot ever conceive of loving yourself at your current weight, then the priority is to address the self-loathing.

If you are unable to leave your home and presume everyone is staring at you and appalled, again the priority is to learn to re-pattern your thoughts towards a balanced sense of self and others.

The advantage of seeking a clinical psychologist to support you in recovery from BED is that the emphasis will be on the techniques you need to apply to help bring from the current disjointed sense of self and self-worth, towards an integrated sense of self.

Of course in many countries, the services of psychologists are not covered by most employment, extended or national health plans, whereas those of psychiatrists are.

If financial limitations are an issue (when aren’t they?) then if you seek a referral from your doctor to a psychiatrist, indicate you would like to see someone who offers different treatment modalities, specifically DBT. Of course the wait times to get in to see psychiatrists are often months and months into the future.

In the meantime, try to cover off three basic things until you begin therapeutic intervention:

  1. Don’t weigh yourself.
  2. Eat a breakfast of no less than 250 calories.
  3. Donate, give away or throw away any clothes that do not fit right now.

Put this on a post-it note and place it on the bathroom mirror or fridge as a reminder:

“I will have good days and bad days but my value is not determined by my weight and I intend to nourish myself at the start of each day.”

 

Get rid of any scales if you are tempted to check in.

These few tips are no replacement for the therapeutic support that you need for a real recovery, but they will hopefully help a bit in the meantime.

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