A 25-year-old woman comes to the office due to weight gain. The patient has gained 4.5 kg (10 lb) since breaking up with her boyfriend and starting a stressful job 4 months ago. She says, "I hate the way I look. I try to limit my portions, but several times a week I end up eating a whole bag of cookies or a quart of ice cream in one sitting, even if I'm not hungry. My stomach is so bloated that I can't fit into my clothes. It is so depressing." The patient has had abdominal discomfort but no nausea or vomiting. Her weight is always fluctuating although she has tried numerous diets over the years. She also does 45 minutes of aerobic exercise 3 times a week. The patient prefers to eat alone because she feels embarrassed and "out of control." She feels guilty about her behavior, and her self-esteem is low. The patient is 160 cm (5 ft 3 in) tall and weighs 60 kg (132 lb). BMI is 23.4 kg/m². Which of the following is the most likely diagnosis?

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11ec25c8_d773_56f4_bc81_f510eb501983_MD0003_00 This patient's recurrent episodes of binge eating and the absence of recurrent unhealthy compensatory behaviors seen in bulimia nervosa (eg, self-induced vomiting, fasting, laxative abuse, excessive exercise) are consistent with binge eating disorder (BED). Diagnosis requires ≥1 episode per week of binge eating (ie, consuming an excessively large amount of food in a discrete period of time) over 3 months. Other characteristic features of BED include a sense of loss of control, eating rapidly until uncomfortably full, eating when not hungry, eating alone due to embarrassment, and distress, depression, disgust, or guilt after overeating. BED is the most common eating disorder. Although many patients with BED are overweight, it also occurs in patients with normal weight, as in this case. The treatment of choice for BED is psychotherapy, with the best evidence for cognitive-behavioral therapy. Additional treatment options for patients with BED who are overweight or obese include behavioral weight loss therapy and pharmacotherapy with the stimulant lisdexamfetamine. (Choice A) This patient describes years of weight fluctuations, suggesting that her abnormal eating behavior predated her recent stressors. Stress often exacerbates underlying disorders. (Choice C) Body dysmorphic disorder is characterized by obsessive preoccupation with nonexistent or slight defects in physical appearance. It is not diagnosed in patients who are mainly concerned about weight and who also meet criteria for an eating disorder. (Choice D) This patient does not engage in the recurrent and excessive compensatory behaviors required to diagnose bulimia nervosa. Her attempts to diet over the years are characteristic of patients with BED, and her 3-times/week exercise regimen is within healthy guidelines. In contrast, patients with bulimia nervosa engage in periods of excessive fasting and/or extreme exercise undertaken specifically to compensate for their binge episodes. (Choice E) Irritable bowel syndrome is characterized by chronic abdominal pain and irregular bowel movements (diarrhea and/or constipation), which this patient does not describe. Educational objective: Binge eating disorder is characterized by episodes of binge eating associated with distress and a sense of loss of control. It is differentiated from bulimia nervosa by the absence of recurrent, unhealthy compensatory behaviors (eg, self-induced vomiting, fasting, excessive exercise). References: Overview of the treatment of binge eating disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26594849) A primer on binge eating disorder diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/26683528) Binge eating disorder. (http://www.ncbi.nlm.nih.gov/pubmed/28477651)

A 25-Year-Old Woman Comes to the Office Due to Weight