Research paperBinge eating behaviours in bipolar disorders
Introduction
Bipolar disorder (BD) is a severe chronic affective disorders associated with significant clinical, social and economic burden, and including high levels of comorbidity. Among these comorbidities, eating disorders such as anorexia nervosa and bulimia nervosa has long been described (Alvarez Ruiz and Gutierrez-Rojas, 2015). More recently, binge eating disorder (BED) has been recognized as a frequent association with BD. BED is characterized by recurrent episodes of binge eating (BE), namely the consumption of excessively large amounts of food in a short period, associated with a sense of loss of control but without inappropriate compensatory behaviours (American-Psychiatry-Association, 2000). In BD, the prevalence of comorbid BED and repeated episodes of BE behaviour is estimated at 15%, and 17%, respectively (Kruger et al., 1996, McElroy et al., 2013, Schoofs et al., 2011, Wildes et al., 2007), compared with 2–5% in the general population (Bruce and Wilfley, 1996, Dingemans et al., 2002, Rand et al., 1997, Smith et al., 1998, Stunkard et al., 1996). Moreover, comorbid BED during BD is associated with more mood instability, residual mood disorders symptoms, comorbid anxiety and addictions, episodes with psychotic symptoms, suicidality, and with obesity, cardiovascular diseases and metabolic syndrome (Hudson et al., 2007, Lundgren et al., 2010, MacQueen et al., 2003, McElroy et al., 2013, Siqueira et al., 2004, Stunkard et al., 1955).
Studies dealing with this topic have been mainly conducted in the United States, yet it has long been suggested that vulnerability to develop eating disorders varies according to cultural and ethnic differences (Kessler et al., 2013). In addition, only one study investigated qualitative eating patterns of BD patients with comorbid BED (Jacka et al., 2011) and cognitive aspects such as restriction, disinhibition and the influence of emotions on eating behaviours, have not been investigated so far. Although BED affects patients with emotional regulation disorders (Kittel et al., 2015), dimensional aspects of BD patients with BE behaviour remain understudied. This is important as “emotional alimentation” (in reaction to negative emotions) is a recognized phenomenon and has been shown to differ from a usual diet, by its qualitative, quantitative and behavioural aspects (Gibson, 2006, Kaplan and Kaplan, 1957).
Another important issue is the diagnostic threshold for BED as it has been suggested that the categorical diagnostic criteria may be too restrictive and under-estimate the prevalence of BE behaviours; a position that appeared to be acknowledged in the recent modifications incorporated in the DSM-5 criteria (the requirements for the frequency and duration of BE behaviour were reduced to 1 binge eating episode weekly for 3 months in DSM-5 compared with a minimum of 2 binge eating days weekly for 6 months in DSM-IV) (McElroy et al., 2016a). As expected, a study of a representative sample of 22,397 adults in the US demonstrated that the prevalence is higher of BED diagnosed using DSM-5 criteria compared with DSM-IV-TR criteria (Cossrow et al., 2016); interestingly, the study also estimated that BED remained under-recognized. However, a review of published studies found little evidence to support the validity and utility of the frequency criterion of the BED categorical diagnosis (Wilson and Sysko, 2009), as multiple BE episodes are prevalent and associated with negative outcomes (Kruger et al., 1996, Wildes et al., 2008). Furthermore, McElroy et al. (2016b) recently showed that BE behaviour predicted BED or bulimia nervosa with a positive predictive value of 0.90 and specificity of 0.96.
Given the findings and uncertainties from the recent literature noted above, the aim of this study was to investigate the prevalence and characteristics of BE behaviour in a sample of BD cases attending specialist BD clinics in France. Cases with and without BE were compared on socio-demographic, clinical, personality and dimensional variables as well as eating habits. Multivariate analysis was used to determine the best combination of variables that differentiated BD cases with BE behaviour from those without BE behaviour.
Section snippets
Methods
An ethical review board approved the assessment protocol and a letter of information was given to each potential study participant. Written informed consent was required from all patients included in the study.
Identification of BE behaviours
The presence or absence of recurrent BE behaviours was established using a validated self-reported questionnaire, namely the French version of Binge Eating Scale (BES) (Brunault et al., 2016, Gormally et al., 1982). The BES contains 16 items, each comprising of 3 or 4 statements related to the presence and severity of key behavioural (eating large amount of food, quickly), affective and cognitive symptoms (guilt, incapacity to stop eating, feeling of loss of control) of any BE episodes. The
Evidence of abnormal eating habits and bodyweight
The presence or absence of Night Eating Syndrome (NES) was assessed using the French version of the Night Eating Questionnaire (NEQ), which is a 14 item self-rated questionnaire that measures 4 factors: nocturnal ingestion of food, evening hyperphagia, morning anorexia and mood/sleep perturbations (Allison et al., 2008). Each item is scored from 0 to 4, with a total ranging from 0 to 52. Individuals with an NEQ score> 26 are considered as having a NES (Lundgren et al., 2006).
We also used a
Dimensions of personality and temperament
To investigate features that are known to be associated with eating disorders and/or with poorer outcome in BD we measured: impulsivity using the Barratt Impulsivity Scale 10 (BIS-10; Patton et al., 1995), emotional reactivity using the Affect Intensity Measure (AIM; Larsen et al., 1986), and emotional lability using the Affective Lability Scale (ALS; Harvey et al., 1989).
Results
The sample comprised of 145 outpatients (F = 82; 57%) of whom 86 (61%) met diagnostic criteria for BD I. The mean age at interview was about 42 years (standard deviation: S.D. 12) and the mean age at onset of BD was about 24 (S.D. 9) years. Of the total sample, 27 patients (18,6%) met criteria for BE behaviour of whom 20 (74%) were female. Thirteen individuals (9% of the total sample) met criteria for a NES.
Discussion
To our knowledge, this is the first study to examine the prevalence of BE in BD cases treated in specialized clinics in France. In this sample, just under one in five cases with BD reported repeated BE behaviours. This finding is consistent with those from other countries (see Appendix Table A3): with the prevalence of BE behaviour ranging from about 6–25% in Germany, USA, Italy and Canada (Fornaro et al., 2010; Kruger et al., 1996; MacQueen et al., 2003; Schoofs et al., 2011; Wildes et al.,
Conclusion
In a sample of patients with BD I and II, we demonstrated that BE behaviour is common and is associated with poor emotional regulation, higher levels of anxiety, emotional eating and/or abnormal restriction of eating habits.
Further research is warranted especially prospective studies to determine if the relationship between BD and BE is bi-directional, influences the timing of help-seeking for BD, and/or whether interventions that target factors known to worsen outcomes in BD, such as
Funding sources
Data for the analyses reported were obtained from the Bipolar Expert Centre consultation supported by the FondaMental Foundation and funded by the Ministry of Health.
Acknowledgements
We would like to thank Assistance Publique – Hôpitaux de Paris, FondaMental foundation, INSERM and Paris Diderot University for their support.
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These authors contributed equally to this work.