1. Chapter 12: Bulimia Nervosa and Binge Eating Disorder
Linda W. Craighead
Margaret A. Martinez
Kelly L. Klump

2. DSM-5 Changes for Eating Disorders
DSM-IV-TR: Eating Disorders (EDs):
Anorexia Nervosa (AN)
Bulimia Nervosa (BN)
Eating Disorder Not Otherwise Specified (EDNOS)
Separate Chapter had Disorders Usually First Diagnosed During Infancy, Childhood, or Adolescence
DSM-5: Feeding and Eating Disorders (FED):
Anorexia Nervosa (AN)
Bulimia Nervosa (BN)
Binge Eating Disorder (BED); in DSM-IV-TR appendix as provisional
Other specified FED
Unspecified FED
- Avoidant/restrictive food intake disorder
- Pica
- Rumination Disorder

3. Rationale for Changes Changes intended to:
Reduce the frequency of the unspecified diagnosis
Establish criteria appropriate for clinical presentations at younger ages
There is some concern that the new criteria may dramatically increase the number of individuals diagnosed with an eating disorder

4. DSM-5 Diagnostic Criteria for BN
BULIMIA NERVOSA
Recurrent episodes of binge eating. Binge eating characterized by BOTH:
Eating an objectively large amount of food, i.e. larger than most people would eat in a similar period of time and under similar circumstances;
A sense of loss of control over eating during the episode.
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain (e.g. self-induced vomiting, misuse of laxatives/diuretics/enemas/other medications)
C. Binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa
Indicates change from DSM-IV-TR criteria

5. Objective Binge Episode
To be classified as an objective binge episode (OBE), individual must:
Consume an objectively large amount of food, that is more than most people would eat in a similar situation and in a discrete period of time (e.g., 2 hours)
Objectively large ≈ 3x the typical portion for that food
1,900 calories on average (Bartholome, Raymond, Lee, Peterson, & Warren, 2006)
Experience a subjective feeling of loss of control over eating

6. Subjective Binge Episode
Subjective binge episode (SBE):
Individual experiences loss of control while eating an amount of food considered normal or small
For example, one bowl of ice cream (SBE) versus a gallon of ice cream (OBE)
700 calories on average (Bartholome, Raymond, Lee, Peterson, & Warren, 2006)
Only OBEs count toward frequency criterion for diagnosis of BN/BED

7. Characteristics of a Binge
Typically occur when individual is alone
May be comprised of high-calorie foods (i.e., ice cream) or healthy foods (i.e., carrots)
Restricted intake before and after binge episode
Can be spontaneous or planned
Triggered by negative/positive emotions, interpersonal stressors, presence of tempting food, violation of a dieting rule, body image dissatisfaction, excessive hunger, and so on

8. Obstacles to Treatment in BN
Bulimia is often not detected until later in the course of illness, often because:
Binge/purge episodes feel habitual and are perceived as problematic
Function of binge episodes as distracting from negative emotions
Conviction that stopping purging behaviors will lead to weight gain
Shame and embarrassment associated with binge/purge behaviors

9. Medical Complications of BN
Medical complications typically associated with purging
Complications include:
Electrolyte abnormalities
Esophageal/gastrointestinal symptoms
Menstrual irregularities
Thyroid dysfunction
Dental problems
Enlarged parotid glands
Decreased stomach motility

10. Proposed DSM-5 Diagnostic Criteria
BINGE EATING DISORDER
Recurrent episodes of binge eating. Binge eating characterized by both:
Eating an objectively large amount of food, that is an amount larger than most people would eat in a similar period of time and under similar circumstances
A sense of loss of control over eating during the episode
Binge eating episodes are associated with at least three of the following:
Eating more rapidly than normal;
Eating until 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
Binge eating occurs, on average, at least once a week for 3 months
E. The disturbance does not occur exclusively during episodes of anorexia nervosa and is not accompanied by inappropriate compensatory behaviors, as in bulimia nervosa.
**Indicates change from provisional DSM-IV-TR criteria

11. Distinction Between BN and BED
Both BN and BED require the presence of objectively large binge episodes (at least 1x/week for 3 months) in individuals who are not significantly underweight
In BED, no inappropriate compensatory behaviors
BED does not require concern about shape/weight, although this is often reported
Both BN and BED can be chronic conditions exacerbated by life stressors

12. Medical complications of BED
Medical complications less common in BED
Most common complaint is gastrointestinal distress associated with binge episodes
Individuals with BED are more often affected by complications of comorbid obesity
Many (but not all) individuals with BED are also overweight/obese
Those individuals with BED who are not overweight are at risk of developing obesity

13. History of Binge Eating
Ancient Greek physicians describe ravenous hunger, or boulimos
James (1743) described case accounts of overeating at times followed by vomiting
Stunkard et al. called attention to night-eating syndrome (1955) and binge eating syndrome (1959)
Boskind-Lodahl and White (1973) published feminist formulation of “bulimarexia”
Russell (1979) labeled this syndrome as “bulimia nervosa”
DSM-5 (2013) recognizes both BN and BED

14. Transdiagnostic Model of Eating Disorders
Proposed by Fairburn et al., a diagnostic approach that focuses on the similarities between various types of eating disorders
Views overevaluation of eating, shape, and weight as the core pathology underlying all eating disorders
Hypothesizes that overevaluation leads to restriction/dieting that, in turn, leads to disordered eating
May explain the high rate of diagnostic crossover in eating disorders
Limitations of the transdiagnostic model:
Many individuals with BED report onset of binge eating before development of weight concerns

15. Epidemiology Using DSM-IV criteria, prevalence of BN is ~0.5% to1.0%
Prevalence of any binge eating symptoms is 5.7%
Using DSM-5 criteria, prevalence of BN is ~2%
~90% of those diagnosed are women
Using DSM-IV criteria, prevalence of BED is ~2% to 5%
Prevalence among individuals seeking weight-loss interventions is higher, ~30%
Using DSM-5 criteria, prevalence of BED is ~3.6% in women and 2.1% in men
More equitable gender distribution (~65% female, 35% male)
Binge eating may be more common among certain minority groups

16. Course Typical age of onset for BN is late adolescence/early adulthood
Individuals with BN often have a history of AN (~10% to 14% of community samples, ~25% to 37% of clinical samples)
Onset of OBEs may be earlier than the age at which the individual meets full diagnostic criteria for BN or BED
Both BN and BED have a chronic course and high relapse rates

17. Comorbidity Common Axis I cormorbidities include:
Mood disorders
Especially major depression and dysthymia
Anxiety disorders
Posttraumatic stress disorder is more common in BN and BED than AN
Substance abuse
Common Axis II comorbidities include:
Borderline personality disorder
Avoidant, dependent, histrionic, and paranoid personality disorders

18. Genetic Risk Factors
AN, BN, and BED have moderate-to-large heritabilities, similar to biologically based illnesses
In girls, genetic risk activated during puberty
In boys, genetic risk remains constant across the lifespan
Estrogen may account for difference in pubertal risk
Some genes have been implicated, including serotonin, neurotrophic, estrogen receptor, and dopamine genes
Dieting and other environmental factors may increase genetic risk

19. Neurobiological Risk Factors
Overactivity in opioid and dopaminergic systems in binge eating resembles that seen in substance use
Neural patterns may vary over course of illness
Hypothesized that overactive reward networks may increase risk for developing binge eating…
…once binge eating develops, binge behaviors may result in down-regulation and hyposensitivity of neural reward pathways

20. Personality Traits Impulsivity Obsessionality Perfectionism
Impulsivity associated with binging and purging
Impulsivity abates with recovery
Obsessionality
Individuals with eating disorders tend to have obsessive-compulsive traits
Perfectionism
May mediate the relationship between eating disorders and obsessive-compulsive symptoms

21. Emotion Dysregulation
Binge eating conceptualized as emotion regulation strategy
Negative affect precedes and maintains onset of binge eating
Negative affect also associated with body dissatisfaction and dieting behaviors, which may compound the relationship between negative affect and binge eating
Although binge eating may momentarily reduce negative affect, episode is often followed by increased negative affect
Compensatory behaviors may reduce negative affect and thus increase as a result of negative reinforcement

22. Cognitive Dysfunction
Cognitive symptoms of BN include:
Appearance overvaluation
Self-worth is disproportionately affected by body shape and weight
Internalization of the thin ideal
Thin cultural standard is fully adopted
Cognitive biases
Attention and memory biased towards information regarding food, weight, and shape
Rigid and obsessive thinking patterns
Thinking characterized by strict and dichotomous patterns

23. Risk Factors Body dissatisfaction Dieting Interoceptive awareness
Leads to negative affect and dieting behavior, which in turn may produce disordered eating
Dieting
Excessive caloric deprivation may trigger binge eating
Interoceptive awareness
Deficits in ability to monitor internal states predicts onset of eating disorder symptoms
Body mass
Higher body mass may contribute to disordered eating through increased body dissatisfaction and dieting behaviors

24. Environmental Factors
Sociocultural pressure
No clear causal relationship between media exposure and onset of eating disorders
Family
Family attitudes and behavior may contribute to thin ideal internalization and the failure to develop effective coping strategies
Childhood sexual abuse
History of abuse is a risk factor for general psychopathology, not specific to eating disorders

25. Assessment Interview measure of eating disorder symptoms
Eating Disorder Examination (EDE): Assesses disordered attitudes and behaviors over past 4 weeks
Four subscales assess restraint, concern about eating, concern about shape, and concern about weight
Structured format ensures assessment of a variety of constructs are assessed
Takes time to complete interview and the extensive training required to use it limits use in clinical settings

26. Assessment, cont Self-report measures of eating disorder symptoms
Questionnaire version of EDE (EDE-Q)
Can be used for diagnostic purposes or to assess dimensions of eating pathology
Eating Disorder Inventory (EDI) and Bulimia Test–Revised (BULIT-R)
Global measures with multiple subscales, often used to assess treatment outcome
Children’s Eating Attitudes Test (Ch-EAT)
Used to assess eating disorders in children

27. Treatment of BN Psychological interventions
Clinical trials have established Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) as optimal treatments
Although CBT may initially be more effective, individuals receiving IPT continue to show improvement over follow-up so no difference in long run
Interventions may be delivered in guided self-help format to increase treatment access
Pharmacological interventions
Antidepressant medications to prevent relapse when medication stopped effective but best to use in combination with CBT
Further research required to determine best treatments for males, older women, and adolescents

28. Treatment of BED Psychological interventions
As with BN, CBT and IPT are effective treatments
Self-help treatments also effective
Behavioral Weight Loss (BWL) often used to treat comorbid obesity, but weight loss is minimal
Pharmacological interventions
Fluoxetine may reduce binge episodes in BED, as in BN, but does not contribute to weight loss
Topirimate thought to control impulsive tendencies
Medications do not seem to confer additional benefit beyond psychotherapy

29. Prevention of Eating Disorders
Programs targeting high-risk individuals more effective than those implemented universally
Prevention programs generally effective in raising awareness of eating disordered symptoms, less effective in reducing risk factors
Novel programs capitalize on cognitive dissonance by asking participants to critique the thin ideal