See letter by Grilo and Udo and article by Braun et al

Dr Mota and Colleagues Reply

To the Editor: We thank Grilo and Udo1 for highlighting their important work on the prevalence and correlates of binge-eating disorder (BED) using data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). With a reworked prevalence estimate of BED that differed slightly from that documented in previous studies using the NESARC-III (0.85% vs 0.80%),2 Grilo and Udo identified a high prevalence of posttraumatic stress disorder (PTSD: 31.6%) among US adults with lifetime BED.3 This association between BED and PTSD remained statistically significant after adjustment for sociodemographic variables and other mental disorders. Similarly, in our study of the NESARC-III cohort,4 we found the prevalence of BED to be elevated among US adults with lifetime PTSD compared to those without (4.1% vs 0.8%). Together, these population-based findings underscore the high comorbidity between BED and PTSD and the concomitant need to understand how to prevent and efficiently treat their co-occurrence. For example, we found that negative cognition and mood symptoms of PTSD, in particular, were associated with a greater number of BED symptoms.5 Thus, psychotherapies focused on addressing negative cognitions and emotions that characterize both BED and PTSD may be helpful in mitigating co-occurring symptoms of these disorders.6

We wish to emphasize, however, the importance of using a dimensional approach to understanding the association between BED and PTSD symptoms. While Udo and Grilo2 found that the prevalence of BED in the general population is relatively low, our study results indicated that between 5.5% and 40.0% of US adults endorsed 1 or more BED symptoms, which varied as a function of trauma exposure and PTSD diagnosis.5 Specifically, we observed a “dose response” relationship in which the number of BED symptoms was lowest in a non–trauma-exposed group, intermediate in the trauma-exposed and subthreshold PTSD groups, and highest in the PTSD group. These findings suggest that the link between PTSD and BED symptoms extends beyond the presence of either diagnosis and that a much larger subsample of trauma-exposed individuals may experience BED symptoms.

Other work from our group suggests that there may be different maladaptive eating typologies in individuals with PTSD that are not necessarily diagnostic. Specifically, among US adults with lifetime PTSD in the NESARC-III, we identified 5 latent classes of maladaptive eating typologies in 41.1% of respondents: broad eating psychopathology (2.2%), low past weight (9.6%), binge eating (6.0%), overeating (19.9%), and restrictive eating and cognitive distortions (3.4%).4 Importantly, individuals in all maladaptive eating typologies had increased odds of several medical conditions relative to individuals with no PTSD and no eating disorder and to those with PTSD and no eating psychopathology.4

We echo Grilo and Udo’s conclusion that future research should strive to understand the mechanisms driving maladaptive eating behaviors such as binge eating among individuals with PTSD. We add that future research should also continue to examine the mental and physical health sequelae of a full range of maladaptive eating behaviors among individuals with PTSD symptoms. The employment of novel approaches such as machine learning7 and network modeling8 may also be informative in elucidating multivariable predictors of PTSD-BED, as well as the complex interplay of these symptoms.6

References

1. Grilo CM, Udo T. Posttraumatic stress disorder and binge eating disorder: further context and additional findings from a nationally representative sample of adults in the United States. J Clin Psychiatry. 2020;81(1):19lr13157.

2. Udo T, Grilo CM. Prevalence and correlates of DSM-5-defined eating disorders in a nationally representative sample of US adults. Biol Psychiatry. 2018;84(5):345–354. PubMed CrossRef

3. Udo T, Grilo CM. Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States. Int J Eat Disord. 2019;52(1):42–50. PubMed CrossRef

4. Sommer JL, Mota N, El-Gabalawy R. Maladaptive eating in posttraumatic stress disorder: a population-based examination of typologies and medical condition correlates. J Trauma Stress. 2018;31(5):708–718. PubMed CrossRef

5. Braun J, El-Gabalawy R, Sommer JL, et al. Trauma exposure, DSM-5 posttraumatic stress, and binge eating symptoms: results from a nationally representative sample. J Clin Psychiatry. 2019;80(6):19m12813. PubMed CrossRef

6. Brewerton T. An overview of trauma-informed care and practice for eating disorders. J Aggress Maltreat Trauma. 2019;28(4):445–462. CrossRef

7. Karstoft KI, Galatzer-Levy IR, Statnikov A, et al; members of Jerusalem Trauma Outreach and Prevention Study (J-TOPS) group. Bridging a translational gap: using machine learning to improve the prediction of PTSD. BMC Psychiatry. 2015;15(30):30. PubMed

8. Armour C, Fried EI, Deserno MK, et al. A network analysis of DSM-5 posttraumatic stress disorder symptoms and correlates in US military veterans. J Anxiety Disord. 2017;45:49–59. PubMed CrossRef

Natalie Mota, PhDa

natalie.mota@umanitoba.ca

Joel Braun, MD, BScb

Robert H. Pietrzak, PhD, MPHc,d

Renée El-Gabalawy, PhDa,e

Jordana L. Sommer, MAe

Karen Mitchell, PhDf,g

aDepartment of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba, Canada

bRady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada

cNational Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, Connecticut

dDepartment of Psychiatry, Yale University School of Medicine, New Haven, Connecticut

eDepartment of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada

fNational Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, Boston, Massachusetts

gDepartment of Psychiatry, Boston University School of Medicine, Boston, Massachusetts

Published online: February 11, 2020.

Potential conflicts of interest: None.

Funding/support: Supported by University of Manitoba, Rady Faculty of Health Sciences Start-up Funds (Drs Mota and El-Gabalawy).

Role of the sponsor: The supporters had no role in the publication of this letter.

J Clin Psychiatry 2020;81(2):19lr13157a

To cite: Mota N, Braun J, Pietrzak RH, et al. Dr Mota and colleagues reply. J Clin Psychiatry. 2020;81(2):19lr13157a.

To share: https://doi.org/10.4088/JCP.19lr13157a

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