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Binge eating disorder is described by frequently repeated episodes of consuming large amounts of food (binging), unlike bulimia nervosa, there are no associated compensatory behaviors such as self-induced vomiting or excessive exercise. It is the most prevalent eating disorder.
Binge eating was not identified as a separate eating disorder before the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, but it was considered as a diagnosis in clinical practice.
It is typically associated with feeling guilty and unable to self-control, which ultimately leads to anxiety and depression.
Binge eating disorder eventually leads to morbid obesity, about half of patients with morbid obesity have an underlying binge eating disorder. Morbid obesity causes deleterious health effects such as ischemic heart disease, malignancies and psychiatric illness, causing high morbidity and mortality.
Management of psychological and physical burden associated with BED requires involvement of medical staff of different specialties e.g. psychiatrists, bariatric surgeons and dieticians, which sometimes leads to a conflicting treatment plans.
Patients with binge eating disorder usually have other comorbid mental illnesses. Research studies showed that approximately three quarters of patients with binge eating disorder suffer from psychiatric comorbidities.
Patients with eating disorders may have poor emotion regulation. When compared to healthy subjects, eating disorders patients had increased levels of emotion intensity and emotion regulation troubles, decreased emotions acceptance and emotional awareness. They also tend to use unhealthy emotion regulation strategies. Furthermore, negative mood usually precedes binge eating episodes in those patients.
Binge eating is thought to be a maladaptive response to the unstable mood. It is viewed as it fills one up, to alleviate the feeling of emptiness.
Pathogenesis of different types of eating disorders may vary according to the underlying personality disorder. Multiple features of borderline personality disorder contribute to the development of specific eating pathology, these features include impulsivity, self-harming, anger, unstable mood and emotions, feeling of emptiness, fear of abandonment and unstable interpersonal relationships.
Borderline personality disorder is an Axis II disorder characterized by long term pattern of behavioral instability in interpersonal relationships, self-image, and mood. Patients with borderline personality disorder are often emotionally unstable, impulsive and deliberately engage in self-harming behaviors. The disorder usually manifests since early adulthood or adolescence.
Patients with an eating disorder and comorbid borderline personality disorder usually has poor response to treatment, worsening psychiatric symptoms and bad prognosis.
Aim of the work
- To determine the frequency of Binge eating disorder in patients with borderline personality disorder.
- To determine if there is a relation between binge eating, impulsivity and emotional regulation.
Subjects and Methods
Type of Study: Cross sectional observational study
Sample size, setting, population:
Okasha Institute of psychiatry, Ain Shams University –located in Western Cairo, serve both urban and rural areas in Cairo and other governorates- Cairo, Egypt.
a) Sample size:
Using PASS program, setting alpha error at 5 % and confidence interval width at 0.1. Result from previous study (Nery et al., 2014) showed that Binge eating was present in 2.3% of Bipolar disorder cases. Based on this, the needed sample is 70 cases taking in account 15% DROP out rate.
b) selection of subjects:
A convenient sample of seventy patients fulfilling the diagnosis of borderline personality disorder as outlined in the DSM-V criteria were recruited in this study from the outpatient clinic and inpatients of Okasha Institute of psychiatry, Ain Shams University.
1. Age: 18-45 years
2. Sex: both sex
3. First Diagnosed borderline personality disorder
1- Comorbid diseases that affects eating behavior, diet or body mass index e.g. DM, thyroid disease and other endocrinal disorders.
2- Other psychiatric diseases that could make assessment difficult e.g., schizophrenia or bipolar disorder.
1- Structured Clinical Interview for DSM-VI Personality Disorders (SCID-II): to diagnose borderline personality disorder and to exclude other personality disorders.
2- Binge Eating Scale (BES): to assess the presence or absence of recurrent binge eating behaviors.
3- Barratt Impulsiveness Scale (BIS); to assess impulsivity.
4- Trait Meta-Mood Scale (TMMS): to measure attention to feelings, clarity in discrimination of feelings, and mood repair.
Regarding social-demographic data of patients, the age of patients range from 18-43 years with mean (25.81 ± 6.34). The majority of patients were females 48 (68.6%).
Regarding the educational level the majority was highly educated 48 (68.6%), and according to occupation the majority was working 26 (37.1%), followed by students and not working, and both had the same percentage 22 (31.4%).
Regarding borderline personality disorder criteria of patients according to SCID II, most of the cases had impulsivity and affective instability 69 (98.6%), followed by fear of abandonment, unstable interpersonal relationships and identity disturbance 65 (92.9%), then chronic feeling of emptiness and difficulty controlling anger 59, 56 (84.3%) (80%) respectively, while recurrent suicide and paranoid ideation/dissociation occupied the smallest percentage 54 (77.1%).
Regarding the degrees of impulsivity according to Barratt Impulsiveness Scale (BIS) we found that all the subjects showed impulsivity with various degree, with a great number of cases showing moderate impulsivity 42 (60%), followed by severe impulsivity 21 (30%) and only 7 cases had mild impulsivity (10%).
Regarding BIS subscale, motor scale was the most affected, means that most of the cases tend to act without thinking, followed by non-planning scale, or lack of future planning and forethought (means: 29.47 and 26.49 respectively). Ability to concentrate and focus attention is the least affected (mean: 22.49).
Regarding presence or absence and severity of binge eating we found that 37 cases suffered from this problem where 21 (30%) had moderate binging, and 16 (22.9%) had severe binging, and only 33 (47.1%) had no binging. The mean ±SD BES was (19.34 ± 9.96) (range between 3 and 41).
Regarding confirmation of BED diagnosis by DSM-V criteria in patients with binge eating behaviors, 26 patients out of 37 patients with binge eating behaviors (70.27%), and out of 70 BPD patients (37.14%) were fulfilled DSM-V criteria of binge eating disorder.
Regarding assessment of emotional regulation by Trait Meta Mood Scale (TMMS), means of attention to feeling, clarity of feeling and repair of mood scores were 35.04, 32.27 and 15.23 respectively.
In relation between binging and social-demographic data of the cases we found no significant relation (p-value>0.05).
Regarding correlation between SCID II criteria of borderline personality disorder and binge eating, we found that there was significant relation between binging and fear of abandonment, which showed that borderline patients cope with their fear of being alone by binge eating, 100% of patients with binge eating had fear of abandonment (p-value 0.02), compared to 84% of non-binging. There was no significant relation between the rest of criteria and binging.
Regarding relation between binging and impulsivity and relation between binging and components of Barratt impulsiveness subscale, there was no significant association between binging and impulsivity (p-value 0.143). Furtherly, there was no statistically significant differences between binging and non-binging groups regarding attentional (p-value 0.943), motor (p-value 0.831), non-planning (p-value 0.326)) and total impulsivity scales (p-value 0.549). The most affected scale for impulsivity in both groups was motor scale followed by nonplanning scale, whereas the least affected scale was attentional impulsivity scale in both groups.
Regarding the relation between binging and results of Trait Meta Mood Scale, cases with binging had lower total score on TMMS signifying their inability to regulate their emotions in comparison to non-binging cases with significant statistical difference (p-value 0.021). Moreover, the clarity of feeling subscale showed a highly significant statistical difference (p-value 0.004) between binging and non binging cases with binging cases having lower mean scores, means that cases with binging are more unable to understand their own emotional state than cases without binging.
Regarding correlation between Trait Meta Mood Scale, Barratt Impulsiveness Scale and Binge Eating Scale, binge eating was found to be inversely correlated with attention to feeling, clarity of feeling and repair of mood, with statistically significant inverse correlation with clarity of feeling (P value= 0.000), the greater inability to understand one’s emotional state, the more binge eating. This means that there is a relation between emotional dysregulation and binging. No significant correlation between binging and impulsivity was found.
Our study found that there are a substantial number of patients with borderline personality disorder suffering from binge eating. Also we found that there is a significant association between emotional dysregulation and the occurance of binge eating.