Comorbidity of binge eating disorder and other psychiatric disorders: a systematic review

Abstract

Objective

Binge eating disorder (BED), although relatively recently recognized as a distinct clinical syndrome, is the most common eating disorder. BED can occur as a separate phenomenon or in combination with other mental disorders, adding to the overall burden of the illness. Due to the relatively short history of recognizing BED as a distinct disorder, this review aimed to summarize the current knowledge on the co-occurrence of BED with other psychiatric disorders.

Method

This review adhered to the PRISMA guidelines. Multiple databases, such as MEDLINE, MEDLINE Complete, and Academic Search Ultimate, were used to identify relevant studies. Of the 3766 articles initially identified, 63 articles published within the last 13 years were included in this review. This systematic review has been registered through INPLASY (INPLASY202370075).

Results

The most frequently observed comorbidities associated with BED were mood disorders, anxiety disorders and substance use disorders. They were also related to more severe BED presentations. Other psychiatric conditions frequently associated with BED include reaction to severe stress and adjustment disorders, impulse control disorder, ADHD, personality disorders, behavioral disorders, disorders of bodily distress or bodily experience, and psychotic disorders. Additionally, BED was linked to suicidality and sleep disorders.

Discussion

The findings highlight the interconnected nature of BED with various psychiatric conditions and related factors, shedding light on the complexity and broader impact of BED on mental health and the need for appropriate screening and appropriately targeted clinical interventions.

Introduction

The understanding of eating disorders (EDs) has evolved significantly in the past decade. In conjunction with the clearly defined bulimia nervosa (BN) and anorexia nervosa (AN), the latest revisions, such as the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [1] released in May 2013 and the 11th revision of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD-11) published in 2019 [2], introduce a distinct category known as binge eating disorder (BED). A comparison of the DSM-5 and ICD-11 diagnostic criteria for BED is shown in Table 1. The introduction of the BED diagnosis was prompted by a significant factor: in earlier iterations of diagnostic systems, the classification of Eating Disorder Not Otherwise Specified (EDNOS) occurred most frequently. Consequently, numerous patients exhibit symptoms of an ED but do not meet the criteria for BN or AN [3]. Empirical studies have demonstrated the utility of incorporating BED into the classification of EDs [3]. Despite being recognized relatively recently as a distinct clinical syndrome, BED stands out as the most prevalent ED in the United States, with a lifetime incidence of 2.8%, surpassing the rates of BN (1%) and AN (0.6%) [4]. Moreover, BED potentially has the highest prevalence among EDs globally, boasting a lifetime prevalence of 1.9%, in contrast to the prevalence of 1% for BN [4]. Like in BN and AN, BED occurs more frequently in women than in men, with a lifetime incidence of 3.5% for women compared to 2% for men [5]. Importantly, in both the DSM-5 and ICD-11, the diagnoses of BED and BN are considered mutually exclusive, meaning that during single episodes, only one of the disorders can be assigned; ICD-11 extends this exclusion to AN. Notably, healthcare professionals face significant deficits in knowledge and awareness regarding BED [6]. This lack of awareness, coupled with feelings of shame, constitutes a primary obstacle preventing most affected individuals from receiving the necessary treatment, despite the existence of effective interventions for BED [6].

Table 1.

DSM-5 and ICD-11 criteria for binge eating disorder

DSM-5	ICD-11
1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:  a. Eating, in a discrete period of time (e.g., within any 2-h period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances  b. The sense of lack of control overeating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)	Binge eating disorder is characterized by frequent, recurrent episodes of binge eating (e.g., once a week or more over a period of several months). A binge eating episode is a distinct period of time during which the individual experiences a subjective loss of control overeating, eating notably more or differently than usual, and feels unable to stop eating or limit the type or amount of food eaten. Binge eating is experienced as very distressing and is often accompanied by negative emotions such as guilt or disgust. However, unlike in Bulimia Nervosa, binge eating episodes are not regularly followed by inappropriate compensatory behaviors aimed at preventing weight gain (e.g., self-induced vomiting, misuse of laxatives or enemas, strenuous exercise).
2. Binge-eating episodes are associated with three (or more) of the following:  a. Eating much more rapidly than normal  b. Eating until feeling uncomfortably full  c. Eating large amounts of food when not feeling physically hungry  d. Eating alone because of being embarrassed by how much one is eating  e. Feeling disgusted with oneself, depressed, or very guilty after overeating
3. Marked distress regarding binge eating is present
4. The binge eating occurs, on average, at least 1 day a week for 3 months
5. The binge eating is not associated with the regular use of inappropriate compensatory behavior (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa
Severity Grading  • Mild: 1 to 3 episodes per week  • Moderate: 4 to 7 episodes per week  • Severe: 8 to 13 episodes per week  • Extreme: 14 or more episodes per week

BED is a condition characterized by intricate interactions between genetic factors and environmental influences. On the one hand, there are indications pointing to a genetic predisposition [7, 8]. Conversely, the prevalence is significantly influenced by the sociocultural environment and the values practiced within it [9]. For instance, migrants in Australia exhibit a lower incidence of EDs than individuals born in the country [10]. Additionally, specific sociocultural groups, such as Latinos and Blacks, have higher prevalence rates than does the general population [9]. BED may occur not only as a separate phenomenon but also in combination with other mental disorders, adding complexity to the overall burden of the disease. Given the relatively brief history of conceptualizing BED as a distinct disorder, this review aimed to systematize the current knowledge regarding the co-occurrence of BED with other psychiatric disorders. The significance of this article is emphasized by the pivotal role that assessing comorbidities plays in treating BED. Tailored therapies designed to enhance the effectiveness of BED treatment can be developed only by thoroughly considering and addressing comorbidities.

Methods

This review was performed according to the updated version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA 2020 Statement) [11].

Search strategy and selection process

We identified relevant studies using multiple databases, including MEDLINE, MEDLINE Complete, and Academic Search Ultimate. The search strings used were ‘binge eating disorder’ AND ‘mental health OR mental illness OR mental disorder OR psychiatric illness’.

Due to the inclusion of BED in the DSM-5, our analysis initially centered on studies from 2013 onwards. However, recognizing significant studies incorporating proposed criteria before official inclusion, we extended the scope to 2010. Eventually, ongoing analysis led to further extension to 2023, with the final literature search encompassing studies published between January 1, 2010, and April 30, 2023. The details concerning the selection process are outlined in Fig. 1.

Fig. 1.

Prisma flow chart

Inclusion and exclusion criteria

The searching strategy and criteria for inclusion and exclusion were established in accordance with the PICO framework, as recommended by the Cochrane Library for systematic reviews [12]. This framework encompasses the population, intervention, comparator, and outcome of interest (see Table 2). We included articles published in English and within the past 13 years. Articles were excluded if they (1) were not related to BED, (2) did not present empirical data, (3) were not scientifically peer reviewed, (4) were duplicated, (5) did not have full-text available, (6) were not related directly to the subject of the review, or (7) put emphasis on bariatric patients. Out of the 3766 articles found during the initial search, only 63 remained after the application of inclusion/exclusion criteria and were included in the final review.

Table 2.

The final inclusion and exclusion criteria using the PICO method

Criteria	Inclusion	Exclusion
Population	Human, any age, any gender	Animal
Intervention	Following types of studies were included: experimental, RCT, cross-sectional, cohort, case–control	Not applicable
Comparison	Not applicable	Not applicable
Outcome	Co-occurrence of BED with other psychiatric disorders	Studies not related to BED
Date	Cutoff date limit of January 1, 2010—April 30, 2023 were applied	Before January 1, 2010
Language	Only studies written in English were included	Non-English language publications

Results

We analyzed the articles in terms of the co-occurrence of BED with other psychiatric disorders. The selected articles addressed issues related to psychiatric comorbidities, such as other feeding or EDs, mood disorders, anxiety, or fear-related disorders (ADs), disorders specifically associated with stress, impulse control disorders, attention deficit hyperactivity disorder (ADHD), substance use disorders, personality disorders, behavioral disorders, disorders of bodily distress or bodily experience, and schizophrenia. Moreover, associations between BED and suicidal thoughts and behaviors, and sleep disorders were observed.

BED as a main diagnosis

Thirty-two articles describing the comorbidity of BED and other psychiatric disorders involved participants with BED as a main diagnosis [13–44] (Table 3).

Table 3.

Co-occurrence of BED with other psychiatric disorders

Reference	BED diagnosis (and measures of other eating behaviors/ED)	other instruments	depression/mood disorders	anxiety disorders	substance use disorders	personality disorders	suicidality	behavioral disorder	PTSD, adjustment, acute stress	psychotic disorders	sleep disorders	impulse control disorder	ADHD	Study sample(s)	Methodology	Key findings
[13]	EDI-II	MMPI-2				■								BED: 55 women, 5 men	cross-sectional	▪ Several putative psychotic phenomena were reported in the sample of binge eaters, and they were related to higher scores on several dimensions of the EDI-2. ▪ At least in some patients, there might be an overlap between some basic phenomena of psychosis (disordered sense of basic self, of bodily experiences, and hyperreflectivity), and those basic disturbances in identity development and Self-schemas which are at the base of eating disorders. ▪ Depression, Hypochondriasis, Psychopathic Deviation, Schizophrenia, Psychasthenia, and Paranoia receiving the highest mean scores.
[14]	SCID-I/P, EDE	BDI, DIPD-IV	■	■	■	■								BED: 259 women, 88 men	cross-sectional	▪ 15% of the sample showed symptoms of avoidant personality disorder features, 12% showed symptoms of obsessive-compulsive personality disorder features, 8% showed features of both disorders, and 66% showed features of neither.
[15]	SCID-I/P, EDE	BDI, DIPD-IV	■		■	■								BED: 259 women, 88 men	cross-sectional	▪ 129 patients showed a co-occurring mood disorder, 34 – substance use disorders, 60 - both, and 124 - neither. ▪ Groups differed on personality disorder features - the highest frequencies were found among those having mood disorder and both mood and substance use disorders. ▪ Groups differed in ED psychopathology (not in BMI and binge-eating (BE) frequency) - groups with mood disorder and both comorbidities demonstrated high concerns on r eating, weight, or shape.
[16]	SCID-I/P, EDE, WEH, QEWP-R, FHRDCI	BDI	■	■	■									BED: 127 overweight women, 39 overweight men	cross-sectional	▪ BED patients with a family history of AD were significantly more likely than BED patients without a family history of AD to have lifetime diagnoses of AD and MD but not SUD. ▪ A family history of anxiety was not significantly associated with timing or sequencing of age at onset of AD, BE, dieting, or obesity, or with variability in current levels of BE, ED psychopathology, or psychological functioning.
[17]	SCID-IP (SCID-II), EDE-Q	BDI-II	■		■	■			■					BED & substance use disorders: 30 women, 8 men	experimental, uncontrolled trial	▪ The participants’ primary problematic substance was alcohol (75%), followed by cannabis (36.4%). ▪ The most common comorbid Axis I category was depression (41%), followed by PTSD (33.3%). ▪ The most frequently observed Axis II category was avoidant personality disorder (20.5%) and depressive personality disorder (20.5%). ▪ After 6-week group Mindfulness-Action Based Cognitive Behavioral Therapy (MACBT) participants significantly improved on measures of objective BE episodes, disordered eating attitudes, alcohol and drug addiction severity, and depression.
[18]	EDI-II, +DSM-IV criteria for BED	BDI, SCL-90, NEO-PI-R	■	■		■					■			BED: 212 women on admission of a CBT day-treatment program for BED. (182 women completed the treatment)	naturalistic follow-up study	▪ Higher scores on depressive symptoms, agoraphobia and extraversion were significantly related to less improvement. ▪ The analyses show that the level of social embedding and psychopathological comorbidity (state and trait) were predictors for treatment outcome.
[19]	Mini-DIPS, EDE-Q	BDI, BAI	■	■										BED: 36 women, 5 men	experimental, randomized controlled trial	▪ At baseline, 33% of the patients suffered from at least one additional mental disorder, and 24% at a 4-year follow-up. ▪ Short-term CBT is efficacious over a 4-year-follow-up period with respect to core symptomatology, ED pathology and depressive symptoms.
[20]	SCID-I/P	PAI Depression Scale	■											BED: 105 overweight women	cross-sectional	▪ 67.27% of women showed lifetime history of depression. ▪ After controlling for age and body-mass index (BMI), depressive symptoms were significantly associated with greater medication use (excluding antidepressants).
[21]	EDE-Q, TFEQ	BDI	■											No ED: 123 overweight women BED: 47 women who do not overvalue shape/weight, 101 women who overvalue shape/weight BN: 53 women	cross-sectional	▪ Both BED groups showed significantly greater ED psychopathology compared to the overweight group. ▪ Within BED, the group with overvaluation showed significantly higher ED psychopathology and depressive levels despite no differences in BE. ▪ BED with overvaluation and BN groups differed little from each other, despite having significantly higher ED psychopathology and depressive levels than the other groups.
[22]	SCID-I/P, EDE	BDI	■											Mild BED: 247 women, 84 men Moderate BED: 294 women, 101 men Severe/extreme BED: 82 women, 26 men	cross-sectional	▪ Higher ED psychopathology has been found in the severe/extreme BED groups (compared to moderate and mild groups). ▪ Higher depression has been found in moderate and severe/extreme groups (compared to the mild group) ▪ Participants characterized with overvaluation (54% of the sample) versus without overvaluation (46% of the sample) did not differ significantly in age, sex, BMI, or BE frequency, but had significantly greater ED psychopathology and depression.
[23]	EDE-Q, QEWP-R	BDI	■											Mild BED: 235 women, 29 men Moderate BED: 57 women, 10 men Overvaluation of shape/weight: 173 women, 23 men No overvaluation of shape/weight: 114 women, 16 men	cross-sectional	▪ The moderate severity group showed greater ED psychopathology but not depression compared to the mild group. ▪ The overvaluation group showed significantly greater ED psychopathology and depression compared to the nonovervaluation group.
[24]	SCID-I/P, EDE-Q		■	■	■									BED & current depressive disorder: 35 women, 5 men	experimental, randomized, 12-week double-blind placebo-controlled trial	▪ The most prevalent depressive disorder diagnosis was recurrent major depressive disorder (63%), followed by single episode of major depressive disorder (23%), and dysthymic disorder (13%). ▪ 30% of the sample showed a lifetime AD, 13% had lifetime SUD. ▪ Treatment with Duloxetine (mean 78.7 mg/day) was superior to placebo in reducing weekly frequency of BE days, BE episodes, weight, and Clinical Global Impression-Severity of Illness ratings for BE, and depressive disorders. ▪ Groups did not differ in terms of changes in BMI and measures of eating pathology, depression, and anxiety.
[25]	SCID-I/P, EDE		■	■										BED: 20 elderly women	case‒control	▪ Elderly women with BED reported an average (SD) of 4.5 (2.9) BE episodes per week. ▪ The most frequent comorbid psychiatric conditions were mood disorders. ▪ Current depression was diagnosed in 15% of the sample, associated lifetime depression in 45% of the sample.
[26]	EDE	CTQ, SCID-I							■					BED: 92 women, 20 men	cross-sectional study	▪ Histories of childhood abuse and PTSD each predicted poorer BE treatment outcome and the association between childhood abuse history and BE treatment outcome differed by PTSD history, such that the association was observed only among participants with a history of PTSD. ▪ Patients with trauma histories benefit less from existing psychotherapy approaches for BED than those without trauma histories, as well as suggest that PTSD may be more influential than the trauma exposure itself.
[27]	EDE-Q	SCID-I/NP	■	■										BED: 151 women Mood/anxiety disorders: 102 women No psychiatric disorders: 259 women	cross-sectional	▪ At the latent level, BED was co-occurring with, yet distinct from, affective and anxiety disorders and was not characterized by an underlying affective or anxiety disorder.
[28]	diagnosis based in ICD-10 criteria		■	■	■	■			■	■			■	AN: 720 individuals BN: 402 individuals BED: 561 individuals HC without psychiatric disorder: 15 500 individuals	retrospective study	▪ Individuals with binge-type ED showed  higher polygenic scores than controls for other psychiatric disorders, including depression, schizophrenia, and attention deficit hyperactivity disorder, and higher polygenic scores for body mass index
[29]	EDE, EDE-Q	CES-D	■			■								BED: 255 women	cross-sectional	▪ Higher levels of interpersonal problems were related to greater NA, and greater NA was associated with higher frequency of BED symptoms and psychopathology. ▪ Patients with BED showed higher levels of interpersonal problems, depression, and ED psychopathology than nonclinical samples.
[30]	SCID-I, TFEQ	BDI	■	■	■							■		PD: 33 women BED: 41 women No ED: 35 women	cross-sectional	▪ ED groups reported significantly greater depressive symptoms, body dissatisfaction, and dietary restraint and more Axis I disorders compared with controls. ▪ Compared with both the obese and normal weight BED groups, PD reported significantly greater dietary restraint and body dissatisfaction. ▪ Compared with obese BED, PD reported lower prevalence of impulse control disorders. ▪ All three ED groups reported significantly greater levels of depression on the BDI than the control group, but no significant differences were found among the ED group.
[31]	Questionnaire including number of items on ED symptoms and behaviors basedon the DSM-IV criteria. Incidence BED-those who met criteria for BED during pregnancy but did not do so in the 6 months period prior to pregnancy.	Hopkins Symptom Checklist-25	■	■	■									BED Incidence: 931 women BED Continuation: 956 women BED Remission: 605 women No ED: 43152 women	cross-sectional	▪ Incidence of BED was significantly associated with lifetime history of being a victim of sexual or physical abuse, symptoms of major depression, symptoms of anxiety and depression, low life satisfaction, low self-esteem, low partner relationship satisfaction, smoking, alcohol use, lack of social support, and several weight-related factors.
[32]	EDI-1	BDI-I, SCL-90, NEO-PI-R	■	■		■					■			BED: 304 treatment-seeking patients (92.7% women)	naturalistic, observational, follow-up	▪ Higher levels of drive for thinness, higher levels of interoceptive awareness, lower levels of BE pathology and, in women, lower levels of body dissatisfaction predicted better outcome in the short and longer term.
[33]	EDE	SCID-I, MCMI-III	■	■	■	■								BED: 17 women BN: 17 women	cross-sectional	▪ Most common clinically significant trait in the BED sample was depressive personality, then avoidant and dependent. ▪ AD were the most common psychiatric diagnoses (47.1% of BED sample), followed by MD (23.5% of BED sample) and substance use disorders (5.9% of BED sample).
[34]	SCID-I, EAT-40, EDI-II, BITE	SCL90-R	■	■	■									BED: 34 women BN-P: 34 women BN-NP: 34 women	cross-sectional	▪ A gradient in psychopathological scores emerged with BN-P patients having higher pathological scores on the SCL-90-R, followed by BN-NP and BED patients.
[35]	SCID-I/P	BDI	■											BED: 182 overweight women, 73 overweight men	cross-sectional	▪ 25.9% of the sample was mildly depressed, 18% was moderately depressed, and 8.2% was severely depressed, measured with BDI. ▪ Higher weight bias internalization was associated with poorer self-reported health on all SF-36 scales, BDI scores mediated the relationship. ▪ WBIS scores mediated the relationship between BDI scores and three SF-36 scales.
[36]	EDE, EES, QEWP	BDI, SCID-II	■			■								BED: 86 women, 15 men	experimental, randomized uncontrolled clinical trial	▪ Analyses identified two moderators of posttreatment outcome, namely, Avoidant Personality Disorder or an earlier onset of overweight and dieting (<15 years old) evidenced significantly worsened outcome when treated with ACGT versus DBT-BED.
[37]	QEWP-R	MINI-Kid	■	■	■		■	■	■	■			■	Adolescents with ED AN: 32 individuals BN: 104 individuals BED: 51 individuals	cross-sectional study	▪ Patients diagnosed with BN or BED showed a higher prevalence of any psychiatric comorbidity (the highest MDD). ▪ Patients diagnosed with BED had the highest prevalence of ADHD and adjustment disorder, compared to BN and AN. ▪ The individuals with BED and ADHD showed a higher prevalence of obesity, compared to individuals with BED without ADHD.
[38]	Study 1: EDE Study 2: SCID-I/P	IDS	■											BED: 122 women, 17 men (community sample)	observational, cross-sectional	▪ Participants with long duration of BE episodes (compared to those with short duration) exhibited greater symptoms of depression and lower self-esteem but did not differ on other measures of ED symptoms.
[39]	EDE-Q, QEWP-R, TFEQ	BDI	■											BED: 152 women BN: 58 women PD: 24 women	cross-sectional	▪ BN and BED groups reported higher levels of depression than PD.
[40]	AUDADIS-5, PRRISM-5		■	■	■	■		■	■					36309 US civilians (56.3% women) BED: 318 individuals BN: 92 individuals AN: 276 individuals No ED: 35709	cross-sectional	▪ 93.8% of respondents with BED met criteria for at least one additional lifetime psychiatric disorder. ▪ The lifetime prevalence rates for all psychiatric disorders were substantially higher in the ED groups than the no-specific ED group. ▪ The lifetime BED group met criteria for significantly greater number of lifetime psychiatric diagnoses than the lifetime AN group. ▪ BED was significantly associated with any MD, MDD, persistent depression, any AD, all individual anxiety disorders (except for panic disorder), PTSD, AUD, any personality or conduct disorders, and all individual personality and conduct disorder.
[41]	SCID-I/P, EDE, EDE-Q	BDI, PANAS	■											Three distinct clinical samples: (a) 118 women with AN (b) 133 women with BN (c) 50 obese men and women; 9 with current BED	3 studies longitudinal cohort, retrospective	▪ Moderate to strong concordance for the measures of negative affective states across all three studies. ▪ Moderate to strong concordance was for the measures of BE and exercise frequency. ▪ The strongest evidence of concordance across measurement approaches was found for purging behaviors.
[42]	EDDS, EDE-Q	BFI, PANAS				■								BED: 20 women, 10 men BN: 47 women, 7 men	cohort	▪ Analysis showed a two-way interaction between neuroticism and NA lability predicting BE fluctuations, indicating that higher NA lability was only related to larger fluctuations in the frequency of BE episodes when present in participants who showed high symptoms of neuroticism. ▪ An interaction was detected between ED diagnosis and NA lability.  this was accounted for by differences in average NA between the diagnoses.
[43]	SCID-I, BED-Q, EDE-Q	MDI	■											BED: 85 women, 13 men	cross-sectional	▪ The prevalence of depression was 56% according to self-reported data (MDI), while 34.7% had a depression diagnosis. ▪ Disease-specific QoL in BED was associated with depression
[44]	EDE, EDE-Q	SCID, BDI-II	■	■	■									BED: 87 women, 13 men	experimental, randomized-controlled trial	▪ 40.59% participants had lifetime MD, 5.94% - current MD, 7.92 – current specific phobia, 3.96% - lifetime alcohol abuse, and 2.97% - lifetime social phobia

ASRS Adult ADHD Self-Report [45], ADHD-RS ADHD Rating Scale-IV-Home Version [46], ASI Addiction Severity Index [47], AUDADIS-5 NIAAA alcohol use disorder and associated disabilities interview schedule-5 [48], BAI Beck Anxiety Inventory [49], BDI Beck Depression Inventory [50, 51], BDI-II Beck Depression Inventory - II [52], BFI Big Five Personality Inventory [53], BITE Bulimic Investigatory Test Edinburgh [54], CES-D Centre for Epidemiologic Studies Depression Scale [55], CTQ Childhood Trauma Questionnaire [56, 57], DIPD-IV Diagnostic Interview for DSM-IV Personality Disorders [58], EAT-40 Eating Attitudes Test [59], EAT-26 Eating Attitudes Test [60], EDDS Eating Disorder Diagnostic Scale [61], EDE Eating Disorder Examination [62], EDE-Q Eating Disorder Examination Questionnaire [63], EDI-1 Eating Disorder Inventory-1 [64], EDI-2 Eating Disorder Inventory-2 [65], EES Emotional Eating Scale [66], FHRDCI Family History- Research Diagnostic Criteria interview [67], IDS Inventory for Depressive Symptomatology [68], LEO-CV Leyton Obsessional Inventory Child Version [69], MCMI-III Millon Clinical Multiaxial Inventory, Third Edition [70], MINI-Kid Mini International Neuropsychiatric Interview for Children and Adolescents [71], MMPI-2 Minnesota Multiphasic Personality Inventory-2 [72], NEO-PI-R NEO-PI-R PERSONALITY INVENTORY-REVISED [73], PAI Depression Scale Personality Assessment Inventory Depression Scale [74], PANAS Positive and Negative Affect Schedule [75], PRISM-5 Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 version [76], QEWP-R Questionnaire for Eating and Weight Patterns Revised [77], SCID-I Structured Clinical Interview for DSM-IV Axis I Disorder - Research version [78], SCID-I/P Structured Clinical Interview for DSM-IV Axis I Disorders–Patient Edition [79, 80], SCID-I/NP Structured Clinical Interview for DSM-IV Axis I Disorders–Non-Patient Edition [81], SCID-II Structured Clinical Interview for DSM-IV Axis II Personality Disorders Self-Report [82], SCL-90 The symptoms checklist-90 [83], SCL90-R The symptoms checklist-90 Revised [84], TFEQ Three-Factor Eating Questionnaire [85], Hopkins Symptom Checklist-25 [86], WEH Weight and Eating History interview [87]

The most common comorbid psychiatric condition among individuals with BED reported in twenty-nine articles was mood disorders [14–25, 27–41, 43, 44]. Sixteen articles examined the relationship between BED and anxiety disorders [14, 16, 18, 19, 24, 25, 27, 28, 30–34, 37, 40, 44], and thirteen examined substance use disorders [14–17, 24, 28, 30, 31, 33, 34, 37, 40, 44]. Twelve articles described the occurrence of symptoms of personality disorders among individuals with BED [13–15, 17, 18, 28, 29, 32, 33, 36, 40, 42]. Five articles indicated the relationship between BED and posttraumatic stress disorder, acute stress disorder or/and adjustment disorders [17, 26, 28, 37, 40]; two articles reported the incidence of attention deficit hyperactivity disorder among individuals with BED as well as relationships between BED and schizophrenia [28, 37]. One article highlighted the prevalence of impulse control disorders among BED individuals [30], and another two articles showed the association between BED and behavioral disorders [37, 40]. In addition to the abovementioned psychiatric conditions, two studies assessed sleep disorders among BED individuals [18, 32], and one article assessed suicidality [37]. The data are summarized in Table 3.

Other clinical and community samples with comorbid BED

Thirty-one articles were found in the case of individuals without BED as a main diagnosis [88–118]. Ten studies examined the prevalence and correlates of BED in clinical samples of patients suffering from other psychiatric conditions [88–97] (Table 4). Six of them included samples of patients with mood disorders [88–92, 97], two studies included patients with OCD [93, 94], and one study assessed BED among patients with heroin use disorder [95]. In summary, the abovementioned studies, which included clinical samples, showed the comorbidity of BED with anxiety disorders, substance use disorders, ADHD, post-traumatic stress disorder (PTSD), behavioral disorders, impulse control disorders, disorders of bodily distress or bodily experience, psychotic disorders, and suicidality.

Table 4.

Binge eating in clinical and community samples

Reference	instruments	depression/mood disorders	anxiety disorders	substance use disorders	Personality disorders	suicidality	behavioral disorder	PTSD, adjustment, acute stress	psychotic disorders	sleep disorders	impulse control disorder	disorders of bodily distress	ADHD	Clinical (Cl)/population-based (Pb)/community (Ct)	Study sample(s)	Methodology	Key findings
[88]	SCID-P	■	■	■		■								Cl	875 outpatients with BD (bipolar I or II)	cross-sectional	▪ 125 (14.3%) patients met DSM-IV criteria for at least one comorbid lifetime Axis I ED, with BED (n=77) being more common than BN (n=42) and AN (n=27). ▪ There were no significant ED comorbidity differences between BD I and BD II patients. ▪ Patients with BD, especially women, not infrequently have comorbid ED, and this comorbidity is associated with an earlier age of onset and more severe course of BD illness.
[89]	SCID, BiB-CQ, BiB-PQ, CIRS	■	■	■		■		■	■					Cl	717 patients 76.3% had BD 9.5% had BED	cross-sectional	▪ BED was associated with a significantly elevated BMI. ▪ Both BED and obesity were associated with greater psychiatric and general illness burden, but illness burden profiles differed. ▪ After controlling for obesity, BED was associated with suicidality, psychosis, mood instability, AD comorbidity, and substance abuse comorbidity. ▪ After controlling for BED status, obesity was associated with greater general medical comorbidity, but lower substance abuse comorbidity. ▪ BED was associated with suicidality, psychosis, mood instability, anxiety disorder comorbidity, and substance abuse comorbidity.
[90]	SCID, BiB-CQ, BiB-PQ, EDDS, CIRS	■	■	■		■			■					Cl	1092 patients with BD (bipolar I or IIdisorder or schizoaffective disorder, bipolar type -SAD, BT)	cross-sectional	▪ 27% of patients had a current DSM-5 ED: 12% had BED, 15% had BN, and 0.2% had AN. ▪ Rates of DSM-5-defined BED and BN were higher than clinical diagnosis rates and rates of DSM-IV-defined BED and BN. ▪ Compared with BD patients without an ED, BD patients with a DSM-5 ED were younger and more likely to be women; had an earlier age of onset of BP; had higher EDDS composite scores and higher degrees of suicidality, mood instability, and AD comorbidity; and had a higher mean BMI, higher rate of obesity, and higher CIRS total scores.
[91]	EDDS, SCID, BiB-CQ, BiB-PQ	■	■	■					■					Cl	1114 BD spectrum patients (diagnosis of bipolar I disorder, bipolar II disorder, or schizoaffective disorder, bipolar type; no current suicidal ideation or psychosis) *No BE behavior (No ED=783, BED=0, BN=0, AN=2) *BE behavior (No ED=33, BED=131, BN=165, AN=0)	cross-sectional	▪ 30% of patients had any BE and 27% had BE plus ED diagnosis. ▪ Compared with bipolar spectrum patients without BE, bipolar spectrum patients with BE were younger and more likely to be female; had significantly higher levels of eating psychopathology, suicidality, mood instability, and AD comorbidity; had a significantly higher mean BMI and a significantly higher rate of obesity; and had a significantly higher medical illness burden. ▪ Bipolar spectrum patients with BE but no ED diagnosis was more similar to bipolar spectrum patients without BE than to those with an ED. Nonetheless, the positive predictive value and specificity of BE predicting an ED was 0.90 and 0.96, respectively.
[92]	MINI-Plus 5.0.0, HDRS-17, MADRS, YMRS, CGI-S, UKU,SEX FX, Klein Trauma and Abuse-Neglect Questionnaire, PDSQ, NEO-FFI, Q-LES-Q, SDS, EWPS, TAQ, RSES, ASRS-v1.1,WURS-25, MDQ	■											■	Cl	631 participants with MDD or BD *501 without BE *130 with BE	cross-sectional	▪ A higher percentage of individuals with BD met criteria for BE when compared to MDD. ▪ Individuals with a MD and BE had greater scores on measures of anxiety severity and higher rates of lifetime and current substance dependence, lifetime alcohol abuse, ADHD, and measures of neuroticism. ▪ BE is common among adults utilizing tertiary care services principally for a MD. ▪ The presence of BE identifies a subset of adults with mood disorders who have greater illness complexity as evidenced by course of illness variables and comorbidity.
[93]	SCID, Y-BOCS, DY-BOCS, OCD natural history questionnaire, BDI	■	■	■		■	■				■			Cl	1001 patients with OCD	cross-sectional	▪ The following variables remained associated with social phobia (SP) comorbidity after logistic regression: male sex, lower socioeconomic status, BDD, specific phobia, dysthymia, GAD, agoraphobia, Tourette syndrome and BED.
[94]	SCID, Y-BOCS, DY-BOCS, OCD Natural History Questionnaire, BDI, BAI, USP-SPS	■	■	■		■					■	■	■	Cl	*1001 with OCD as the main diagnosis (153 OCD+PD, 49 OCD+AG, 202 OCD +PD/AG)	cross-sectional	▪ AG was correlated to dysthymia, BDI-II, SP, impulsive-compulsive internet use, BN, and BED. ▪ Patients with PD/AG were also more likely to be married and to present high anxiety, separation anxiety disorder, major depression, impulsive-compulsive internet use, generalized anxiety, posttraumatic stress, and BED. ▪ Patients with OCD associated with AG exhibited greater rates of comorbid social phobia, impulsive–compulsive internet use, BN and BED.
[95]	API, YFAS, BIS-11, EAT			■		■								Cl	100 men with HUD (28 with food addiction, 78 without FA) 100 controls	cross-sectional	▪ BED was more prevalent in patients with HUD (21%) than in control subjects (8%).
[96]	SCID, C-BEDS	■											■	Cl	252 patients (children)	cross-sectional	▪ 12% (n=31) of the sample had BE. ▪ There was a significant association between ADHD and BE, BE partially mediates the association between ADHD and BMI z-scores.
[97]	PDSQ-ED, MINI, IDS-C, QIDS-C, CAST, CHRT, ASRM	■	■			■								Cl	482 patients with MDD	experimental, single-blind placebo-controlled trial	▪ 95 patients experienced BE symptoms. ▪ Patients with MDD experiencing BE symptoms were characterized by higher scores of negative self-outlook, negative outlook of future, irritability, comorbid anxiety disorders (generalized anxiety disorder, panic disorder, social phobia, OCD, hypomanic symptoms, and suicidality. ▪ BE symptoms (OR = 2.02; 95% CI = 1.06-3.84) and depression severity (OR = 1.04; 95% CI = 1.00-1.08) were independently associated with lifetime attempted suicide.
[98]	CIDI	■	■	■		■	■							Pb	10123 adolescents aged 13 to 18 years	cross-sectional	▪ Lifetime prevalence estimates of BED and sBED (subclinical BED) were 1.6% and 2.5%. BED was more prevalent in girls. ▪ The 12-month prevalence rates of BED and sBED were 0.9% and 1.1%. ▪ 83.5% of BED participants and 70.1% of sBED participants met criteria for at laest 1 other lifetime DSM-IV disorder. ▪ BED was strongly associated with mood and anxiety disorder. 37% of adolescents with BED endorsed 3 or more classes of comorbid disorders. ▪ BED was related to suicide attempts, substane abuse or dependence, and behavioral disorders.
[99]	DISC-2	■	■											Pb	833 adolescent girls (mean age = 15.7 ± 0.5 years)	cross-sectional	▪ The prevalence was 10.8% for girls suffering from sBED. ▪ Girls with sBED had a 3.5-fold increase in the odds of suffering from MD diagnosis (95%CI=2.3-17.1, P£0.001), 3.2-fold increase in the odds of suffering from DY diagnosis (95%CI=1.4-7.2,P£0.006), and 1.8-fold increase in the odds of suffering from anxiety symptoms of GA (95%CI=1.0-3.2,P£0.04).
[100]	SSAGA	■												Pb	3,226 European American (EA) and 550 African American (AA) young adult women (twins) from the Missouri Adolescent Female Twin Study.	cohort study	▪ Results suggest that common familial influences underlie MDD and OE-BE, and the magnitude of familial influences contributing to the comorbidity between MDD and OE-BE is similar between EA and AA women.
[101]	CIDI	■	■	■		■	■							Pb	10,123 adolescents and 2,980 adults	cross-sectional	▪ Among adults and adolescents, BED was associated with elevated odds ofsuicide ideation, plan, and attempt at a univariate level. ▪ Most adolescents experienced suicidality onset following BED onset, whereas most adults experienced suicidality onset prior to BED onset. ▪ The proportion of individuals with BED who had mood (adolescentsonly), anxiety (adults ages 30–44 years only), and behavioral disorders (adolescents and adults ages 30–44 years) was greater among those with versus without suicidality.
[102]	CIDI							■						Pb	2392 men, 3310 women	cross-sectional	▪ Most women and men with AN, BN, and BED reported a history of interpersonal trauma. ▪ Rates of PTSD were significantly higher among women and men with BN and BED. ▪ Subthreshold PTSD was more prevalent than threshold PTSD among women with BN and women and men with BED.
[103]		■	■	■										Pb	6140 participants at the age of 14 (55.5% females) 5069 participants at the age of 16 (58.7% females)	longitudinal,population-based, prospective cohort study	▪ All ED were predictive of later AD. ▪ AN, BN, BED, PD, and OSFED were prospectively associated with depression (BED: OR = 2.00, 95% CI = 1.06-3.75). ▪ All ED but AN predicted drug use and deliberate self-harm subthreshold BED: OR = 2.32, 95% CI = 1.43-3.75). ▪ Although BED and BN predicted obesity, AN was prospectively associated with underweight.
[104]	SDQ, BET												■	Pb	2,672 adolescents, comprising 186 adolescents with ADHD (148 boys, 38 girls) and 2,486 adolescents without ADHD (1,186 boys, 1,300 girls)	cross-sectional (data from longitudinal study)	▪ Boys with ADHD appear to be at a greater risk of regular BE classified by DSM-5 criteria at 14-15 years of age. ▪ Overall, the risk for ED symptoms and partial-syndrome diagnoses in adolescents with ADHD does not appear to be high at 14-15 years of age when using DSM-5 criteria with population-based sampling.
[105]		■	■	■				■					■	Pb	4719 participants aged 18-44 (52.1% females)	cross-sectional	▪ Lifetime ADHD was strongly and significantly associated with lifetime BN, BED, and any ED in unadjusted models, but not with AN or subthreshold BED. ▪ After adjusting for demographic variables and psychiatric comorbidities, all associations of lifetime ADHD with EDs were substantially attenuated, and only the association of ADHD with BN remained statistically significant. ▪ Similar results were found using past-12-month diagnoses.
[106]	CIDI												■	Pb	9282 participants	cross-sectional	▪ In both sexes, those with lifetime and past 12-month BE and BED had significantly higher prevalence of ADHD than those without BE and BED, respectively. ▪ Women with lifetime and past 12-month BN and lifetime AN also had significantly higher prevalence of ADHD compared with women without these diagnoses.
[107]	EDE-Q, EDI-2, BDI	■	■	■				■						Pb	8,694 females	cross-sectional	▪ 133 females had BN, 185 had BED. ▪ 366 females had PMDD, 3,489 had PMS. ▪ Prevalence of PMDD and PMS were 17.4 and 55.4% among those with BN, 10.7 and 48.9% among those with BED and 3.4 and 59.1% among those with subthreshold BED. ▪ After adjustment for age, race/ethnicity, income, education, body mass index, age at menarche, birth control use, and comorbid mental health conditions, PMDD was associated with seven times the odds of BN (OR 7.2, 95% CI 2.3, 22.4) and PMS with two times the odds of BN (OR 2.5, 95% CI 1.1, 5.7). Neither PMDD nor PMS were significantly associated with BED.
[108]	K-SADS-PL	■	■	■			■						■	Pb	30,532 children and adolescents aged between 6 and 18 years	cross-sectional study	▪ 45.6% of participants diagnosed with feeding and eating disorders had no other psychiatric comorbidity, 27.7% had one other psychiatric comorbidity, 10.6% had two comorbidities and 16.1% had three or more psychiatric comorbidities. ▪ Obsessive–compulsive disorder, agoraphobia, MD, SP, oppositional defiant disorder, GAD, ADHD, PD, and conduct disorder were significantly higher among children and adolescents with feeding and eating disorders (BED included) compared to their peers without feeding and eating disorders.
[109]	SCOFF, CIS-R, AUDIT, SADQ-C, TSQ, SFQ	■	■	■		■		■						Pb	*7001 participants (3907 females, 3094 males)	cross-sectional	▪ Adults assigned to ED type classes are at increased risk for mental health comorbidities and poorer social functioning. ▪ Binge eaters were at higher odds for having a panic disorder or phobia, GAD, or mixed anxiety-depressive disorder.
[110]	WMH-CIDI	■	■				■	■						Ct	2268 participants (1234 in Mexico and 1034 in the US)	cross-sectional	▪ The lifetime prevalence of BED was 1.6% in Mexico and 2.2% among Mexican-Americans. ▪ Compared with Mexicans in families with migrants, risk for BED was higher in US-born Mexican-Americans with two US-born parents (aHR = 2.58, 95% CI 1.12–5.93). This effect was attenuated by 24% (aHR = 1.97, 95% CI 0.84–4.62) with adjustment for prior-onset depressive or anxiety disorder. Adjustment for prior-onset conduct disorder increased the magnitude of association (aHR = 2.75, 95% CI 1.22–6.20).
[111]	SCID, CAPS	■		■				■						Ct	432 male and 67 female veterans (including 28 couples in which both partners were veterans) who screened positive for trauma histories and/or a probable DSM-IV PTSD diagnosis	cross-sectional	▪ Lifetime rates of BN and BED diagnoses were comparable to civilian populations, and a considerable range of lifetime and current BN and BED symptoms were identified. ▪ PTSD and depression severity were most consistently associated with BN and BED symptom severity, with depression most strongly associated with EDs for women.
[112]	SCID-I/P, CIS-R	■	■											Ct	14,088 adults 841 (6%) with BE	cross-sectional (part of cohort study)	▪ Those with depressive episodes had twice the prevalence of BE. ▪ Those with anxiety disorders had a 77% higher prevalence of BE. ▪ Those who reported MADD had a 42% higher prevalence of BE (mixed anxiety and depressive disorder).
[113]	SCID-I	■												Ct	*Finnish women twins born 1975-1979, participated in five surveys from age 16 until their mid-thirties. At Wave 4 (mean age 24 years), the women (N = 2,825) underwent a 2-stage screening for eating disorders.	logitudinal cohort study	▪ 16 women who met DSM-5 criteria for BED were detected, yielding a lifetime prevalence of 0.7% (95% confidence interval [CI] 0.4–1.2%). ▪ Of women with BED, only two had a history of other ED, but six had lifetime MDD.
[114]	SCID	■	■	■				■						Ct	Two studies of veterans and their intimate partners (453 men and 307 women)	cross-sectional	▪ 10 women (3.3%) and 15 men (3.3%) met lifetime criteria for BED. ▪ For women, the strongest positive correlation has been found between BED and dysthymia, GAD, and panic disorder. ▪ In men, GAD and agoraphobia were positively related to BED the most. ▪ A model with AN, BN, and BED symptoms loading onto the distress subfactor of the internalizing domain fit the data best in the full sample and the male and female subsamples. This model was statistically equivalent for men and women. ▪ All three EDs (AN, BN, BED) loaded onto distress, indicating that these conditions overlap with psychopathology characterized by negative affect.
[115]	EDE-Q, ISU, K-10, SF-12	■	■	■										Ct	794 Australian women initially recruited for 9-year assessment, 357 who completed the follow-up survey at T2 were analyzed	cross sectional & longitudinal	▪ Recurrent Binge Eating (RBE) and ISU comorbidity was 5.88% in this nonclinical sample and having one condition increased the likelihood of the other. The two conditions had a different trajectory over two years whereby ISU participants had significant risk of developing RBE in addition to or in place of their ISU but the reverse was not found for RBE participants.
[116]	ASRS, BES												■	Ct	277 college students  (170 women 107 men)	cross-sectional study	▪ BED symptomatology was associated with increased ADHD symptomatology and a higher BMI among both men and women. ▪ Between BED symptomatology and ADHD symptomatology and between BED symptomatology and BMI were found to be significant among both men and women.
[117]	MINI, GAIN-SS	■	■	■		■	■	■	■	■				Ct	4,889 first-year college students	cross-sectional study	▪ BPB (especially binge eating) are relatively common and associated with mental health problems. ▪ Binge eating only was significantly associated with 5 of 8 mental health problems with elevated odds for both internalizing (depression, anxiety, insomnia, posttraumatic stress, and suicidality) and externalizing emotional problems inattentiveness, hyperactivity, impulsivity, and conduct disorder, substance use and abuse, (problematic use, substance abuse, and dependence), and crime/violence-related problems (interpersonal, property, and drug-related crimes).
[118]	BES, TFEQ, YFAS, DASS-21	■	■											Ct	94 adultts with disinhibited eating	community-based feasibility randomized controlled trial	▪ 68 participants had a diagnosis of BED, 19 – BN, 39 – comorbid depressive symptoms, and 43 – comorbid anxiety

ASRS Adult ADHD Self-Report [45], API Addiction Profile Index [119], ASRM Altman Self-Rating Mania [120], AUDIT Alcohol Use Disorders Identification Test [121], BAI Beck Anxiety Inventory [49], BDI Beck Depression Inventory-II [50, 51], BES Binge Eating Scale [122], BET Branched Eating Disorders Test [123], BiB-CQ Bipolar Biobank Clinical Questionnaire [89], BiB-PQ Bipolar Biobank Patient Questionnaire [89], BIS-11 Barratt Impulsivity Scale-version 11 [124], BITE Bulimic Investigatory Test Edinburgh [54], CAST Concise Associated Symptoms Tracking [125], CAPS Clinician Administered PTSD Scale [126], C-BEDS Children’s Binge Eating Disorder Scale [127], CGI-S Clinical Global Impressions-Severity of Illness scale [128], CHRT Concise Health Risk Tracking [125], CIRS Modified Cumulative Illness Rating Scale [129], CIS-R Clinical Interview Schedule Revised [130], DASS-21 Depression anxiety and stress scale [131], DISC-2 Diagnostic Interview Schedule for Children-version 2 [132], DY-BOCS Dimensional Yale–Brown Obsessive–Compulsive Scale [133], EAT Eating Attitudes Test [59], EDDS Eating Disorder Diagnostic Scale [61], EDE-Q Eating Disorder Examination Questionnaire [63], EDI-2 Eating Disorder Inventory-2 [65], EWPS Endicott Work Productivity Scale [134], GAIN-SS Global Appraisal of Individual Needs Short Screener [135], HDRS Hamilton Depression Rating Scale‑4 [136], IDS-C Inventory of Depressive Symptomatology-Clinician Rating [137], ISU Illicit Substance Use [138], K-10 Kessler-10 item distress scale [139], MADRS Montgomery-Asberg Depression Rating Scale [140], MDQ Mood Disorder Questionnaire [141], MINI Mini International Neuropsychiatric Interview [142], NEO-FFI NEO-Five Factor Inventory [73], OCD Natural History Questionnaire (Leckman: Yale OCD Natural History Questionnaire, unpublished), PDSQ Psychiatric Diagnostic Screening Questionnaire [143], Q-LES-Q Quality of Life Enjoyment and Satisfaction Questionnaire [144], QIDS-C16 Quick Inventory of Depressive Symptomatology [145], RSES Rosenberg Self-Esteem Scale [146], SADQ-C Severity of Alcohol Dependence Questionnaire [147], SCID-I Structured Clinical Interview for DSM-IV Axis I Disorder - Research version [78], SCID-I/P Structured Clinical Interview for DSM-IV Axis I Disorders–Patient Edition [79, 80], SCOFF questionnaire [148], SDQ Strengths and Difficulties Questionnaire [149], SDS Sheehan Disability Scale [150], SEX FX Sex Effects Scale [151], SF-12 12-Item Short-Form Health Survey [152], SFQ Social Functioning Questionnaire [153], SSAGA Semi-Structured Assessment for the Genetics of Alcoholism [154], TAQ Trimodal Anxiety Questionnaire [155], TSQ Trauma Screening Questionnaire [156], TFEQ Three-Factor Eating Questionnaire [85], UKU Udvalg for Kliniske Undersøgelser Side Effect Rating Scale [157], USP-SPS USP-Sensory Phenomena Scale [158], WMH-CIDI World Mental Health Composite International Diagnostic Interview [159], WURS-25 Wender Utah Rating Scale-Short Form [160], Y-BOCS Yale–Brown obsessive-compulsive scale [161, 162], YFAS Yale Food Addiction Scale [163], YMRS Young Mania Rating Scale [164]

Twelve articles reported data on the prevalence and correlates of BED in population-based samples [98–109]. These studies showed the associations of BED with mood disorders, anxiety disorders, substance use disorders, behavioral disorders, PTSD, and ADHD.

Seven articles presented in Table 4 included samples of children and/or adolescents [96, 98, 99, 101, 103, 104, 108] and reported data indicating that among these groups, BED co-occurs with mood disorders, anxiety disorders, ADHD, substance use disorders, behavioral disorders, and suicidality.

Finally, nine articles described the results of studies conducted on community samples [110–117]. Mood disorders, anxiety disorders, behavioral disorders, PTSD, substance use disorders, ADHD, suicidality, psychotic disorders, and sleep problems were found among the correlates of BED in these groups.

Discussion

To the best of our knowledge, this is the first review aimed at consolidating current insights into the comorbidity of BED with other psychiatric disorders. An examination of 63 articles published in the last 13 years revealed associations between BED and various mental disorders, with mood disorders (55 articles), anxiety disorders (36 articles), and substance use disorders (31 articles) emerging as the most prevalent coexisting diagnoses with BED. Other psychiatric conditions that have been found to co-occur with BED include reaction to severe stress and adjustment disorders, impulse control disorder, ADHD, personality disorders, behavioral disorders, disorders of bodily distress, and schizophrenia. Furthermore, this study highlights that BED is associated with suicidality and sleep–wake disorders. Considering the abundance of articles demonstrating elevated co-occurrence rates of mood disorders, anxiety disorders, and substance use disorders among individuals with BED, the findings presented in this manuscript mark a crucial stride toward developing personalized treatment approaches. This objective can be achieved through the implementation of naturalistic study designs that incorporate the treatment of comorbidities, particularly given the evidence indicating that the co-occurrence of mood, anxiety, and/or substance use disorders is associated with a more severe course of BED.

Despite available data pointing to the co-occurrence of BED with psychotic disorders e.g., [28, 39, 91] and impulse control disorders e.g., [30, 93], these connections have received limited attention. A significant avenue for future research lies in exploring the comorbidity of BED with symptoms associated with compulsive sexual behavior disorder, a novel diagnostic entity recently included in the ICD-11 under impulse control disorders. Furthermore, although there is a scarcity of published research on the comorbidity of BED with behavioral disorders and disorders of bodily distress, existing data suggest associations with these psychiatric conditions.

Existing data suggest that BED is linked to an elevated psychiatric and general illness burden. The presence of binge eating behavior may contribute to increased illness complexity, impacting the course of illness and comorbidity, as evidenced in various studies e.g., [92]. Moreover, some studies indicate that individuals with BED are more prone to higher levels of suicidality, as well as substance abuse or dependence [89–91, 101].

Regarding treatment efficacy, a study conducted by Robinson and colleagues [36] demonstrated that dialectical behavior therapy (DBT) outperformed active comparison group therapy (ACGT) for individuals with BED who had comorbid avoidant personality disorders or an earlier onset of overweight and dieting (< 15 years old). In a study by Touchette and colleagues [99] involving patients undergoing cognitive behavioral therapy (CBT), it was found that the degree of social embedding and psychopathological comorbidity (both state and trait) served as predictors of treatment outcomes. Higher scores on depressive symptoms, agoraphobia, and extraversion were correlated with less improvement.

Overall, our findings endorse the general assumption of the relationship between BED and general psychopathology. It is crucial for mental health providers to recognize this association to effectively address the diagnostic and therapeutic challenges associated with BED. As conceptualized in our study, impulsive overeating serves as one of the regulatory behaviors aimed at coping with negative emotions e.g., [15, 17, 91]. These traits are commonly associated with mood, anxiety, impulse control, attention deficit and hyperactivity, and personality disorders [13–44]. Hence, accurately diagnosing and addressing the underlying psychopathology may also prove beneficial in mitigating this compensatory behavior and alleviating its associated psychological and physical (including metabolic) consequences. A clinical implication from our review is the need to screen for other psychiatric conditions in patients with BED and to identify BED symptoms in those with disorders like personality disorders, ADHD, mood, anxiety, and impulse control disorders. This approach ensures a more accurate diagnosis and more effective treatment plans, improving overall patient outcomes as co-occurring conditions can impact the severity and treatment response of BED.

Limitations

Several limitations of this systematic review warrant brief acknowledgment. Firstly, our literature search was limited to articles published in English, potentially limiting the breadth of available results on the topic. This is particularly noteworthy given that the development of BED appears to be influenced by cultural and socioeconomic factors. Secondly, a significant challenge in comparing selected studies arises from the diverse methodologies employed. While the majority of the relevant studies are cross-sectional, there is a scarcity of data from longitudinal studies or experimental trials, both uncontrolled and randomized controlled. Thirdly, we did not conduct a risk of bias assessment for the included studies. As a result, the potential impact of bias in the included studies on our overall findings should be interpreted with caution. The last limitation of our systematic review is the selection of the temporal scope of the analyzed articles. Due to the inclusion of BED in the DSM-5, initially our analysis focused on studies published from 2013 onwards. However, considering the emergence of significant studies incorporating proposed criteria before BED's official inclusion in the classification, we decided to extend the temporal scope back to 2010. Ultimately, due to ongoing analysis and research efforts, we opted to further extend the temporal scope to 2023.

Conclusions

In conclusion, our systematic review affirms BED as the most prevalent ED, with mood and anxiety disorders being the most common co-occurring conditions. A diagnosis of BED is frequently found in individuals experiencing major depressive disorder, bipolar disorder, or obsessive–compulsive disorder. The heightened presence of symptoms such as depression, anxiety, substance use, and suicide risk underscore the importance of considering these factors in the treatment of individuals diagnosed with BED. Conversely, patients, especially those presenting with mood, anxiety, or substance use disorders, should also be screened for BED. Further research is warranted to elucidate the connections between BED and psychotic disorders, as well as disorders of bodily distress.

Authors’ contributions

EK contributed to the conceptualization, methodology, literature search, data curation, writing – original draft preparation, review and editing. MB contributed to the literature search, data curation, and original draft preparation. JE contributed to the review and editing. MLS contributed to conceptualization, methodology, review and editing, and manuscript supervision.

Funding

In the preparation of this manuscript, Ewelina Kowalewska, Magdalena Bzowska and Michal Lew-Starowicz were financially supported by the Centre of Medical Postgraduate Education (statutionary funding, program no 501–1-065–38-23).

Availability of data and materials

The data analyzed in this study are available from the corresponding author with a reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.