# 105 - 6B82 Binge eating disorder # 6B82 Binge-eating disorder 407 Feeding and eating disorders Boundaries with other disorders and conditions (differential diagnosis) Boundary with anorexia nervosa Individuals with anorexia nervosa may engage in binge eating and purging, but can be distinguished from individuals with bulimia nervosa by their very low body weight. If binge eating and purging are associated with very low body weight (i.e. BMI of less than 18.5 kg/m2 in adults and BMI for age under the 5th percentile in children and adolescents), and all the other diagnostic requirements are met, a diagnosis of anorexia nervosa, binge-purge pattern, rather than bulimia nervosa should be assigned. Moreover, a significant proportion of individuals with anorexia nervosa continue to exhibit binging or purging behaviours after they have regained a more normal weight. In such cases, the diagnosis may be changed to bulimia nervosa after 1 year during which body weight has not been sufficiently low to meet the diagnostic requirements of anorexia nervosa. Boundary with binge-eating disorder Binge eating that is not associated with regular compensatory behaviours should be diagnosed as binge-eating disorder rather than bulimia nervosa. Binge-eating disorder Essential (required) features • Frequent, recurrent episodes of binge eating (e.g. once a week or more over a period of 3 months) are required for diagnosis. Binge eating is defined as a discrete period of time (e.g. 2 hours) during which the individual experiences a loss of control over their eating behaviour and eats notably more or differently than usual. Loss of control over eating may be described by the individual as feeling like they cannot stop or limit the amount or type of food eaten; having difficulty stopping eating once they have started; or giving up even trying to control their eating because they know they will end up overeating. • The binge-eating episodes are not regularly accompanied by inappropriate compensatory behaviours aimed at preventing weight gain. • The symptoms and behaviours are not better accounted for by another medical condition (e.g. Prader-Willi syndrome) or mental disorder (e.g. a depressive disorder), and are not due to the effects of a substance or medication on the central nervous system, including withdrawal effects. • There is marked distress about the pattern of binge eating, or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. During the earlier phases of the disorder, symptoms may be concealed and functioning maintained through significant additional effort. 6B82 Feeding and eating disorders | Binge-eating disorder Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Additional clinical features • Binge-eating episodes may be “objective”, in which the individual eats an amount of food that is larger than most people would eat under similar circumstances, or “subjective”, which may involve eating amounts of food that might be objectively considered to be within normal limits but are subjectively experienced as large by the individual. In either case, the core feature of a binge-eating episode is the experience of loss of control over eating. • Additional characteristics of binge-eating episodes may include eating much more rapidly than usual, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, or eating alone because of embarrassment. • Binge eating is typically experienced as very distressing. This is often manifested in negative emotions such as guilt, disgust or shame, which also typically negatively affect the individual’s self-evaluation. • When there are multiple binge-eating episodes per week and these are associated with significant distress, it may be appropriate to assign the diagnosis after a shorter period (e.g. 1 month). • Binge-eating disorder is often associated with weight gain over time and obesity. However, individuals with binge-eating disorder may be of normal weight or even low weight (although not sufficiently to meet the diagnostic requirements for anorexia nervosa). The diagnosis of binge-eating disorder is based on the presence of regular binge eating that is not accompanied by regular inappropriate compensatory behaviours, regardless of overweight status. • Preoccupation with one’s body weight or shape, frequent checking or avoidance of checking body weight or size, and strong influence of body weight or shape on self-evaluation are commonly present, although not required for a diagnosis of binge-eating disorder. Boundary with normality (threshold) • Infrequent overeating or feasting during culturally sanctioned holidays or occasional celebrations should not be characterized as binge eating for the purpose of assigning a diagnosis of binge-eating disorder. • Individuals who report patterns of overeating that do not meet the definition of binge eating should not be diagnosed with binge-eating disorder. Examples include mindless eating that can be resisted or stopped (e.g. if there is a distraction or interruption), or eating more than originally intended without a sense of loss of control, even if this kind of eating is distressing. Feeding and eating disorders | Binge-eating disorder 409 Feeding and eating disorders Course features • Onset of binge-eating disorder is typically during adolescence or young adulthood, but can also begin in later adulthood. • The experience of loss of control over eating or sporadic episodes of binge eating may occur prior to the onset of binge-eating disorder. • Binge-eating disorder is more common among individuals seeking weight-loss treatment. Typically, these individuals seek weight-loss treatment after the onset of the disorder; binge eating does not typically arise as a consequence of treatment. • Binge-eating disorder occurs more often among overweight and obese individuals than those with normal BMI. • Individuals who seek treatment for binge-eating disorder are typically older in age compared to individuals who seek treatment for other feeding and eating disorders. • Binge-eating disorder, although often persistent, has a higher rate of remission than other feeding and eating disorders, with remission sometimes occurring spontaneously. • The features of binge-eating disorder may evolve over time, such that another feeding or eating disorder may better characterize the current symptoms. Developmental presentations • In children, as in adults, binge-eating disorder is associated with weight gain, increased body fat, concealing one’s eating and use of binge eating to regulate emotions. • Binge-eating disorder is more difficult to diagnose in childhood due to normative difficulty engaging in introspection in order to articulate reasons for binge-eating behaviour. Children are likely to report feeling out of control while eating rather than indicating that the amount of food consumed was excessive. • Children with binge-eating disorder may experience less frequent and briefer binges than adults because they typically cannot gain access to food without the assistance of adults. • Binge-eating disorder is common among adolescents and young adults. Culture-related features • Compared to other feeding and eating disorders, binge-eating disorder appears to be more equally distributed across countries, ethnic groups and genders. The prevalence of binge-eating disorder is at least as high in low- and middle-income countries as across high-income countries, and tends to correlate with rise of BMI in the general population. Feeding and eating disorders | Binge-eating disorder