Binge-Eating Disorder: Prevalence, Predictors, and Management in the Primary Care Setting

In contrast to the controversy regarding amount of food, the majority of studies suggest that BED binge eating episodes fall within the 2-hour duration specified by the DSM-5 criteria, although longer durations have been reported [13]. The loss of control (LOC) criterion also appears to be relatively well-supported across studies [13,14]. LOC is a key defining feature of a binge eating episode for individuals with and without BED [15–18].Furthermore, the emotional distress associated with loss of control has been associated with depressive symptoms, appearance dissatisfaction, and poorer mental health-related quality of life [19]. In contrast, one study found that 18.6% of self-reported binges were not associated with loss of control [20]. Of note, there is some concern that the focus on LOC in the diagnostic criteria may lead to under diagnosis of BED among men, as women with BED were more likely than men to identify LOC as a core aspect of a binge eating episode [17].

The second DSM-5 criterion for BED requires that BE episodes be associated with 3 or more of the following: (a) eating more rapidly than normal; (b) eating until uncomfortably full; (c) eating large amounts of food in the absence of hunger; (d) eating alone because of embarrassment about how much one is eating; and (e) feeling disgusted with oneself, depressed, or very guilty after overeating. This criterion is not as controversial as the first, and has correspondingly not received as much attention in the BED literature. However, results from a handful of studies provide some support for their inclusion, particularly in light of the fact that individuals are only required to endorse 3 of the 5 symptoms [13–15,17,21].

The third criteria for BED requires that individuals experience “marked distress” about BE. Only one known study has directly evaluated the distress criterion, and its validity was confirmed by results that suggested individuals with full-threshold BED had significantly greater ED-related psychopathology and depressive symptoms as compared to individuals who met all but the distress criteria for a BED diagnosis [22].

The fourth criteria for BED stipulates that BE occurs an average of once a week for 3 months. Previously, DSM-IV-TR required more frequent episodes, at least 2 days a week for 6 months, but this was criticized as lacking in empirical basis [23]. The current state of the evidence suggests that, with regard to frequency of BE episodes, BED best fits a continuous model rather than a categorical model. That is, symptoms and related impairment exist across a severity spectrum as a function of how often BE episodes occur. For example, in a critical review, Wilson and Sysko noted that individuals with sub-threshold frequency of BE episodes had less severe psychopathology than those meeting criteria for DSM-IV BE frequency (ie, at least 2 days a week for 6 months), but they were still significantly more impaired than those who did not binge eat [24]. The authors asserted that there was no empirical rationale for preserving the criteria of 2 binge days per week for 6 months, and indeed, DSM-5 adopted a more relaxed standard. As is the case with symptoms of many psychological disorders, there does not appear to be a definitive and concrete point at which binge eating becomes pathological [23]. Fortunately, reliability for the new criteria is good and appears superior to the DSM-IV criteria [25].