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Letter to the Editor

Posttraumatic Stress Disorder and Binge-Eating Disorder: Further Context and Additional Findings From a Nationally Representative Sample of Adults in the United States

Carlos M. Grilo, PhDa; and Tomoko Udo, PhDb

Published: February 11, 2020

See reply by Mota and article by Braun et al

Posttraumatic Stress Disorder and Binge-Eating Disorder: Further Context and Additional Findings From a Nationally Representative Sample of Adults in the United States

To the Editor: Braun and colleagues1 recently published an analysis of associations between trauma exposure, posttraumatic stress disorder (PTSD) symptoms, and binge eating symptoms using data from the third wave (2012-2013) of the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III; N = 36,309). They reported that both subthreshold and threshold PTSD are associated with a great number of binge eating symptoms,1 which represents important new information regarding the associations among DSM-5-defined PTSD and binge eating symptoms.2 However, Braun and colleagues1 did not reference or incorporate relevant epidemiologic findings from NESARC-III3-5 that provide important complementary contexts for their findings regarding the relationship between PTSD and binge eating.

Using NESARC-III data, Udo and Grilo3 previously reported that 31.6% (SE = 2.50) of respondents with lifetime binge-eating disorder (BED) diagnoses also met criteria for PTSD; risks remained significantly elevated after adjusting for sociodemographic variables (adjusted odds ratio [AOR] = 6.24, 95% confidence interval [CI] = 4.66-8.35) and even after additionally adjusting for diagnoses of other psychiatric disorders (AOR = 1.74, 95% CI = 1.21-2.50). Udo and colleagues4 further reported that NESARC-III respondents with lifetime BED who reported histories of suicide attempts were significantly more likely to have lifetime diagnoses of PTSD than those without histories of suicide attempts (58.4% vs 24.1%). Importantly, these previous studies used recoded BED variables created by Udo and Grilo5 (after inspection of the NESARC-III dataset revealed various errors) to calculate prevalence estimates of DSM-5 eating disorder diagnoses in US adults (see supplemental tables of Udo and Grilo5 for detailed operationalization and rescoring of the BED diagnosis, and see Udo and Grilo6 for discussion of assessment complexities). Using these diagnosis variables, Udo and Grilo5 found prevalence estimates of 0.85% (SE = 0.05) for lifetime BED and 0.44% (SE = 0.04) for 12-month BED, which differs from the 0.80% lifetime prevalence reported by Braun et al1 and Afifi et al.7

The symptom-level associations between PTSD and binge eating reported by Braun et al1 in the context of diagnostic-level findings previously reported by Udo and Grilo3,4 provide further support for clinical findings that persons with these profiles represent a challenging or more severe subgroup. For example, Grilo and colleagues,8 using diagnostic interviews reliably administered by doctoral research-clinicians, found that 24% of a consecutive series of treatment-seeking women with BED met criteria for PTSD and that those women were characterized by significantly elevated rates of mood, anxiety, and drug use disorders along with greater eating disorder psychopathology, even after adjusting for anxiety disorder comorbidity.

Finally, Braun et al1 speculated that co-occurrence between PTSD and binge eating symptoms might be understood through self-medication and food addiction hypotheses whereby binge eating serves as a coping or reward method. We emphasize that further research is needed to critically examine potential shared and unique mechanisms underlying binge eating and “addictive” behaviors.9,10 Future research should also examine the prognostic importance of PTSD for BED outcomes; to date, limited research has not found psychiatric comorbidity to dampen treatment outcomes in controlled trials for BED,11,12 although, to our knowledge, PTSD has not been tested as a predictor or a moderator of treatment outcomes.13

Carlos M. Grilo, PhDa
Tomoko Udo, PhDb

aDepartment of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
bDepartment of Health Policy, Management, and Behavior, School of Public Health, University of Albany, State University of New York, Albany, New York

Published online: February 11, 2020.
Potential conflicts of interest: The authors report no financial or other conflicts of interest with respect to the content of this letter. No academic, pharmaceutical, or industry entity influenced the preparation of this letter in any manner. More generally, Dr Grilo reports receipt of grants from the National Institutes of Health (NIH), consulting fees from Sunovion and Weight Watchers, honoraria from scientific conferences for lecture presentations and CME activities, and academic book royalties from Guilford Press and Taylor & Francis.
Funding/support: Dr Grilo was supported, in part, by grants from the National Institutes of Health (R01 DK114075, R01 DK112771, R01 DK49587).
Role of the sponsor/disclaimer: The NIH had no role or influence on the content of the letter, nor does the content reflect the views of the NIH.

J Clin Psychiatry 2020;81(2):19lr13157

To cite: 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(2):19lr13157.
To share:
© Copyright 2020 Physicians Postgraduate Press, Inc.



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

2.American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

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.Udo T, Bitley S, Grilo CM. Suicide attempts in US adults with lifetime DSM-5 eating disorders. BMC Med. 2019;17(1):120. PubMed CrossRef

5.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

6.Udo T, Grilo CM. Reply to: Insight May Limit Identification of Eating Disorders. Biol Psychiatry. 2019;85(11):e57-e58. PubMed CrossRef

7.Afifi TO, Sareen J, Fortier J, et al. Child maltreatment and eating disorders among men and women in adulthood: results from a nationally representative United States sample. Int J Eat Disord. 2017;50(11):1281-1296. PubMed CrossRef

8.Grilo CM, White MA, Barnes RD, et al. Posttraumatic stress disorder in women with binge eating disorder in primary care. J Psychiatr Pract. 2012;18(6):408-412. PubMed CrossRef

9.Schulte EM, Joyner MA, Potenza MN, et al. Current considerations regarding food addiction. Curr Psychiatry Rep. 2015;17(4):563. PubMed CrossRef

10.Schulte EM, Grilo CM, Gearhardt AN. Shared and unique mechanisms underlying binge eating disorder and addictive disorders. Clin Psychol Rev. 2016;44:125-139. PubMed CrossRef

11.Masheb RM, Grilo CM. Examination of predictors and moderators for self-help treatments of binge-eating disorder. J Consult Clin Psychol. 2008;76(5):900-904. PubMed CrossRef

12.Grilo CM, Masheb RM, Crosby RD. Predictors and moderators of response to cognitive behavioral therapy and medication for the treatment of binge eating disorder. J Consult Clin Psychol. 2012;80(5):897-906. PubMed CrossRef

13.Vall E, Wade TD. Predictors of treatment outcome in individuals with eating disorders: a systematic review and meta-analysis. Int J Eat Disord. 2015;48(7):946-971. PubMed CrossRef

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