Recurrent binge eating without compensatory behaviors; most common eating disorder.
Also known as: BED, binge eating disorder, compulsive overeating
Overview
Recurrent episodes of binge eating without recurrent inappropriate compensatory behaviors, occurring on average >=1/week for >=3 months, with marked distress, and associated features such as eating rapidly, until uncomfortably full, when not hungry, alone due to embarrassment, or with subsequent disgust/depression/guilt.
Epidemiology
Lifetime prevalence ~1-3% (most common eating disorder in US adults). Female-to-male ratio ~1.5:1. Strongly associated with obesity though not all patients are obese.
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Question 1PsychiatryMedium
A 34-year-old woman is referred by her primary care physician after disclosing recurrent episodes of eating unusually large amounts of food in under 2 hours with a sense of loss of control, occurring twice weekly for the past 6 months. She eats alone because she is embarrassed and feels disgusted and guilty afterward. She reports no vomiting, laxative use, or compensatory exercise. Her BMI is 33 kg/m2. Which of the following is the strongest risk factor for this disorder?
AHistory of childhood maltreatment
BHistory of repeated dieting attempts
CFamily history of eating disorders
DFemale sex as opposed to male sex
Reveal answer & full explanation
Correct answer: C — Family history of eating disorders
AHistory of childhood maltreatment
BHistory of repeated dieting attempts
CFamily history of eating disorders✓
DFemale sex as opposed to male sex
Why Family history of eating disorders is correct
Binge eating disorder (BED) is highly heritable, and a first-degree family history of an eating disorder confers the greatest relative risk, reflecting shared genetic vulnerability in reward and impulse-control pathways.
Familial and genetic loading outweighs demographic and behavioral exposures in magnitude of effect, which is why it is the single strongest predisposing factor for this patient.
Why the others are wrong
History of repeated dieting attempts: dietary restraint is a real precipitant that can trigger binge episodes, but its effect size as a predisposing factor is smaller than heritable family loading.
History of childhood maltreatment: trauma and adverse childhood experiences raise risk for many psychiatric disorders, including BED, but the association is nonspecific and weaker than a first-degree family history of an eating disorder.
Female sex as opposed to male sex: BED is somewhat more common in women (female-to-male ratio about 1.5:1), but it is the eating disorder with the most balanced sex distribution, so sex is a weaker predictor than family history.
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Family history of eating disorders, obesity, mood disorders
Childhood obesity, dieting history
Trauma, adverse childhood experiences
Mood, anxiety, ADHD, substance use comorbidity
Female sex
Pathophysiology
Dysregulated reward processing with altered dopaminergic signaling and impaired prefrontal inhibitory control. Negative affect and dietary restraint serve as binge precipitants.
Clinical presentation
Symptoms
Episodes of eating a large amount of food in <2 hours with loss of control
Associated features (>=3): rapid eating, eating until uncomfortably full, eating when not hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty afterward
Marked distress regarding binge eating
No regular compensatory behaviors
Signs / physical exam
Often obesity-related findings: HTN, dyslipidemia, type 2 diabetes, OSA
No specific physical signs unique to BED
Differential diagnosis
Bulimia nervosa — Binge + compensatory behaviors
MDD with overeating — Hyperphagia during depressive episodes without loss-of-control quality
Night eating syndrome — Consumption of >=25% of daily intake after dinner or nocturnal awakenings to eat
Hypothalamic/genetic obesity syndromes — Prader-Willi, leptin deficiency — early onset, hyperphagia without loss of control concept
Diagnostic workup
Diagnostic criteria
DSM-5-TR: (A) Recurrent binge eating episodes; (B) Associated with >=3 of: rapid eating, eating until uncomfortably full, eating when not hungry, eating alone from embarrassment, feeling guilty/disgusted; (C) Marked distress; (D) Occurs on average >=1/week for >=3 months; (E) Not associated with recurrent compensatory behaviors and not exclusively during anorexia or bulimia. Severity by frequency: mild 1-3, moderate 4-7, severe 8-13, extreme >=14 episodes/week.
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