4. Eating disorder not otherwise specified

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The eating disorder not otherwise specified (EDNOS) category is a conceptually problematic one and comprises a clinically heterogeneous group of diagnoses (262, 263). This "everything else" category currently consists largely of individuals with subsyndromal anorexia nervosa or bulimia nervosa who do not meet DSM-IV-TR criteria of being 15% below expected weight or who binge and purge slightly less than twice per week. Such individuals merit treatment similar to that of full-syndrome patients. In addition, the EDNOS category lumps together normal-weight patients who purge, individuals who chew and spit out their food without swallowing it to prevent weight gain, and patients with binge eating disorder. Also perhaps suitable for this "other" category are individuals who experience psychiatric impairment related to the abuse of diet pills and diuretics (264), individuals who are obsessively preoccupied with liposuction (265) to deal with issues of shape and weight, and certain new-onset postgastrectomy eating disorder patients (266). The EDNOS diagnosis covers a wide spectrum, so no easily generalizable comments can be made for the entire group regarding course or prognosis (267). In addition, over time, considerable movement occurs from one eating disorder diagnostic category to another, including EDNOS (263).

Binge eating disorder is the most discrete and well-studied EDNOS subgroup. Although binge eating disorder is currently not an approved DSM-IV-TR diagnosis, research criteria listed in DSM-IV-TR consist of disturbances in one or more of the following spheres: behavioral (e.g., binge eating), somatic (obesity is common, although not required), and psychological (e.g., body image dissatisfaction, low self-esteem, depression). Empirically supported strategies for the treatment of binge eating disorder include nutritional counseling and dietary management; individual or group behavioral, cognitive behavioral, dialectical behavioral, psychodynamic, or interpersonal psychotherapy; and medications. In reviewing the available information on treating binge eating disorder, it is important to consider the focus of treatment. Most programs using nutritional rehabilitation and counseling focus on weight loss as the primary outcome, whereas studies of psychotherapy and medication generally consider reduction of binge eating as the primary outcome measure, with weight loss as a secondary outcome. Clinical consensus suggests that psychodynamic psychotherapy may also be helpful to reduce binge eating in some patients.


a) Nutritional rehabilitation and counseling: effect of diet programs on weight and binge eating symptoms

The literature on treating binge eating disorder suggests that 1) behavioral weight control programs incorporating low- or very-low-calorie diets may help patients lose weight and usually reduce symptoms of binge eating; 2) at least some degree of weight gain often follows weight loss; 3) weight gain after weight loss may be accompanied by a return of binge eating patterns; and 4) various combinations of diets, behavior therapies, non-weight-directed psychosocial treatments, and even some "nondiet/health at every size" psychotherapy approaches may be of benefit in reducing binge eating and promoting weight loss or stabilization in various circumstances (268).

Some believe that patients with a history of repeated weight loss followed by weight gain ("yo-yo" dieting) or patients with an early onset of binge eating might benefit from following programs that focus on decreasing binge eating rather than losing weight (269, 270). However, at this point, there is little empirical evidence to suggest that obese binge eaters who are primarily seeking weight loss should receive different treatment than obese individuals who do not binge eat.


b) Other psychosocial treatments: effects on binge eating disorder

CBT is the most widely studied treatment for binge eating disorder, and there is substantial evidence supporting its efficacy for behavioral and psychological symptoms, whether it is delivered in the individual or group format. IPT and dialectical behavior therapy have also been shown to be effective for behavioral and psychological symptoms and can be considered as alternative therapies. There is less consensus regarding the long-term effects of treatment; however, some studies suggest that most patients continue to show behavioral and psychological improvement at 1-year follow-up (271, 272). There is a substantial body of evidence supporting the efficacy of self-help and guided self-help CBT treatment programs (273–277) and their use as an initial low-burden step in a sequenced treatment program.

Because severe dieting may disinhibit eating and lead to compensatory overeating and binge eating (278), and because chronic calorie restriction can also increase symptoms of depression, anxiety, and irritability (279), alternative therapies have been developed that use a "nondiet" approach and focus on self-acceptance, improved body image, better nutrition and health, and increased physical movement (280–282). Addiction-based 12-step approaches, self-help organizations, and treatment programs based on the Alcoholics Anonymous model have been tried, but no systematic outcome studies of these programs are available.

In sum, there appear to be several good psychotherapeutic options for treating binge eating disorder when a reduction in binge eating is the primary goal. Weight loss, particularly in the long term, is a much more elusive goal, not only for obese patients with binge eating disorder but for obese patients in general. However, several studies suggest that at least for some patients at certain stages of recovery, behavioral weight control may be a useful treatment component. Also, because studies have found that binge eating may begin before obesity or dieting (283), specific approaches are needed for nonobese patients struggling with binge eating symptoms. The optimal sequencing of treatments—that is, whether the treatment of binge eating should precede or occur concurrently with weight control treatment—has yet to be definitively determined.


c) Medications

There is substantial evidence to suggest that treatment with antidepressant medications, particularly SSRI antidepressants, is associated with at least a short-term reduction in binge eating, in most cases without substantial weight loss. The dosage of medication is typically at the high end of the recommended range. The appetite-suppressant medication sibutramine also appears to be effective in suppressing binge eating, at least in the short term, and is additionally associated with significant weight loss (284). Heart rate and blood pressure need to be monitored closely in patients taking sibutramine, and the medication should be discontinued if there are significant elevations in these parameters, although these side effects seem to be uncommon (285). Finally, the anticonvulsant medication topiramate appears to be effective in reducing binge eating and promoting weight loss in the short (286) and long (287) term, although side effects such as cognitive problems, paresthesias, and somnolence may limit its clinical utility for some individuals. The anticonvulsant zonisamide may produce similar effects (288). Dexfenfluramine, although effective for reducing binge eating (289), has been removed from the market because of increased risk of primary pulmonary hypertension and heart valve abnormalities. Patients who report having used fenfluramine and phentermine in the past should be screened for potential cardiac and pulmonary complications.

It is important to note that in several studies, the placebo response rate has been reported to be quite high. The clinical implications of this finding are that controlled studies are extremely important, as a positive response in an open study may be nonspecific, and short-term beneficial responses to treatment should be viewed cautiously, given that a transient "honeymoon" effect of initiating treatment is common.


d) Combined psychosocial and medication treatment strategies

There have been few studies of combined treatment for binge eating disorder, so the clinical recommendations are preliminary. Overall, it appears that for most patients, the addition of antidepressant medication to behavioral weight control and/or CBT does not significantly augment binge suppression but may confer additional benefits in weight reduction (290–294). One study reported that the addition of the weight-loss medication orlistat to a guided self-help CBT program yielded additional weight loss (295). Another study found that fluoxetine in the setting of group behavioral treatment did not augment binge cessation or weight loss but did reduce depressive symptoms (294). Thus, the addition of medication to psychotherapy for binge eating disorder is not, in most cases, associated with additional benefit on the core symptom of binge eating, perhaps because psychosocial treatments are quite effective for this symptom. However, medication augmentation may have additional benefits.


e) Treatment strategies for night eating syndrome

The phenomenon of wakeful nighttime eating, variously characterized as night eating syndrome, nocturnal eating/drinking syndrome, or nocturnal sleep-related eating disorders, is currently an area of active research (296). Although formal agreed-upon definitions for these syndromes do not yet exist, the construct of night eating syndrome, first described by Stunkard et al. (297), generally includes morning anorexia, evening hyperphagia, and insomnia. In contrast, the construct of nocturnal eating/drinking syndrome emphasizes a sleep disorder with recurrent awakenings often accompanied by eating or drinking, and the construct of nocturnal sleep-related eating disorders adds to this a reduced level of awareness or recall of nocturnal eating episodes. Sleep-related eating disorders, including somnambulism, have reportedly been induced by risperidone, olanzapine, and bupropion, among other medications (298–300). The literature does not, at this point, support the recommendation of particular treatments for these disorders. However, there is preliminary evidence supporting the utility of progressive muscle relaxation (301) and sertraline (302, 303). Further studies of the phenomenology and treatment of these disorders are needed.


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