A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

B. The binge-eating episodes are associated with three (or more) of the following:

1. eating much more rapidly than normal

2. eating until feeling uncomfortably full

3. eating large amounts of food when not feeling physically hungry

4. eating alone because of being embarrassed by how much one is eating

5. feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once a week for three months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (i.e., purging) and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Rationale

Binge Eating Disorder is one of the disorders in the DSM-IV appendix. It is recommended that it be formally included as a disorder in DSM-5.

The rationale for recommending inclusion of binge eating disorder (BED) in DSM-5 is based on a comprehensive literature review (Wonderlich, Gordon, Mitchell, Crosby, & Engel, 2009). Below we address several key recommendations offered by Kendler et al. as they apply to BED.

Consistent with Kendler et al’s recommendation for making decisions about diagnoses in the Appendix, the Eating Disorders Work Group addressed the question, “Should the BED diagnosis should be a) deleted from the appendix, b) promoted to the main manual, or c) retained in the appendix.

Synopsis of the Review of Validators.

The following comments are organized according to the structure of the table of validators provided by Kendler et al. (2009) and based on a literature review (Wonderlich et al., 2009). BED has been compared to both other eating disorders (i.e., anorexia nervosa, bulimia nervosa) and obesity in validational studies. Overall, BED distinguishes itself from other eating disorders and obesity across a wide range of validators, including high priority validators.

In terms of antecedent validators, there is evidence from family history studies that BED tends to run in families and is not a simple familial variation of obesity. Furthermore, in comparison to other eating disorders, BED shows a relatively distinct demographic profile with a greater likelihood of male cases, older age, and a later age of onset. 

Regarding studies of concurrent validators, BED is also differentiated from obesity in terms of greater concerns about shape and weight, more personality disturbance, and a higher likelihood of psychiatric comorbidity in the form of mood disorders and anxiety disorders. Also, BED is associated with lower quality of life than obesity.

Finally, in terms of predictive validators, BED may be differentiated from other eating disorders in terms of its lower level of diagnostic stability and greater likelihood of remission.  In clinical course, BED also shows a greater likelihood of medical morbidities (e.g., self-reported weight gain and metabolic syndrome indicators) than is typically seen in other eating disorders, or in obesity. Finally, in studies of treatment response, there is evidence that individuals with BED have a more positive response to specialty treatments than to generic behavioral weight loss treatments in terms of reduction of eating disorder psychopathology.  These findings suggest some evidence of clinical utility of the BED diagnosis in terms of treatment selection; for example, antidepressant medication is useful in the treatment of BED, but is not generally useful in the treatment of obesity.
Level of change: Major.

References: Literature review (Wonderlich et al., 2009).

Criterion D:

In the DSM-IV appendix, it was suggested that the frequency of binge-days, as opposed to binge episodes, be assessed, and a minimum average frequency of twice/week over 6 months be required. A literature review indicated that criteria identical to those for Bulimia Nervosa would not change caseness significantly. Therefore, Criterion D for BED is recommended to be similar to criterion C for Bulimia Nervosa.

Level of change: Clarification/Modest/substantial.

References: Literature review (Wilson & Sysko, 2009).

Literature Cited:

Wilson GT, Sysko R: Frequency of binge eating episodes in bulimia nervosa and binge eating disorder: Diagnostic considerations. Int J Eat Disord 42:603-610, 2009.

Severity Criteria

This disorder is currently listed in Appendix B of DSM-IV: “Criteria Sets and Axes for Further Study.”  The work group is proposing that this disorder be moved from the Appendix to a free-standing diagnosis in DSM-5.