(p. 205) Evidence-Based Treatment Approaches for Night Eating Disorders
Night Eating Syndrome: Definition, Diagnosis, and Prevalence
In the nearly 60 years between the first description of night eating syndrome (NES) in 1955 (Stunkard, Grace, & Wolff, 1955) and the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), the first manual to describe the proposed diagnostic criteria for NES formally, specific diagnostic criteria for the disorder have evolved considerably. These changes and inconsistencies in the assessment measures used in NES research studies (Striegel-Moore, Franko, & Garcia, 2009; Striegel-Moore, Franko, May, et al., 2006) have complicated cross-study comparison and slowed advances in understanding NES. Currently, NES is classified as an otherwise specified feeding or eating disorder (OSFED; American Psychiatric Association, 2013).
Current DSM-5 diagnostic criteria for NES include recurrent episodes of night eating, including nocturnal ingestions characterized by waking from sleep and eating or excessive consumption of food after the evening meal; awareness and recall of night eating; and significant distress or functional impairment associated with the night eating. The night eating cannot be better accounted for by changes in the sleep cycle, cultural norms, binge-eating disorder (BED), another psychiatric disorder, substance abuse or dependence, a general medical disorder, or medication side effects.
(p. 206) Before the DSM-5 criteria were drafted, an international meeting was held in April 2008 to develop a consensus for proposed diagnostic criteria for NES (Allison, Lundgren, O’Reardon, et al., 2010). This description conceptualized NES as a disorder of delayed circadian intake of food and offered additional guidance on criterion requirements; for example, the proposed criteria from the 2008 consensus meeting detail that for “recurrent, excessive evening intake,” at least 25% of food intake would have to be consumed after the evening meal, on average, for at least 3 months (Allison, Lundgren, O’Reardon, et al., 2010). In addition, nocturnal ingestions were required to occur at least twice per week for 3 months. Evening hyperphagia and nocturnal ingestions often occur together, but only one of these criteria was required for the concept of delayed circadian rhythm of food intake to be met.
Although differential diagnosis with other psychiatric disorders should be made carefully, depression and anxiety often co-occur with NES, and their presence does not automatically preclude a diagnosis of NES. In addition, NES can be diagnosed comorbidly with another eating disorder (Allison, Lundgren, O’Reardon, et al., 2010). In fact, among individuals with NES, approximately 7–25% also met criteria for BED as described in the fourth edition, text revision of the DSM (Allison, Grilo, Masheb, & Stunkard, 2005; American Psychiatric Association, 2000; Greeno, Wing, & Marcus, 1995; Stunkard et al., 1996; Tzischinsky & Latzer, 2004). In addition, approximately 40% of individuals with bulimia nervosa (BN) in an inpatient treatment center had night eating symptoms (Lundgren et al., 2011), and roughly 50% of outpatients with BN reported night eating symptoms (Lundgren, Shapiro, & Bulik, 2008). These rates of diagnostic overlap with BED are consistent with those reported in a large Swiss sample of young adults aged 18–26 years (Fischer, Meyer, Hermann, Tuch, & Munsch, 2012); however, this sample included a lower rate (10%) of diagnostic overlap between NES and BN.
The criteria for NES indicate that persons may have just one of the two core criteria—evening hyperphagia or nocturnal ingestions—to receive a diagnosis. Patients often meet both these criteria, but when only evening hyperphagia is present, the differential diagnosis with BED becomes more challenging. Generally, persons with NES graze throughout the evening and feel compelled to eat to relax and fall asleep. This is qualitatively different than eating an objectively large amount of food in a driven way and experiencing a sense of loss of control. Those with NES also generally display a delayed pattern of eating such that they skip breakfast. With BED, binge-eating episodes occur during times of opportunity, and one prime time for these episodes may be at night. Further work is needed to understand the overlap between these phenomena.
When nocturnal ingestions are present, the diagnostic overlap between NES and BED seems less evident. Intake during these episodes can be objectively large but often is the size of a meal or snack. Those with NES typically describe that they (p. 207) feel driven to eat to fall back to sleep and may feel irritable and distressed when prevented from eating. Vinai and colleagues (2014) showed that this belief in the need to eat to fall asleep was the differentiating factor between patients with NES, BED, and insomnia. Persons with NES also seem to diverge from those with other eating disorders in that alexithymia has not been linked to the severity of night eating symptoms as it typically is with BN, BED, and anorexia nervosa (Vinai et al., 2015).
Physicians may aim to treat NES by helping their patients sleep more soundly by prescribing sleep medications; however, with these medications, persons with NES typically still arouse from sleep and seek food but may do so in a somnolent state with little awareness and recall of their actions. This experience is consistent with sleep-related eating disorder. As such, sleeping pills, such as zolpidem, are contraindicated for the treatment of NES (Howell & Schenck, 2009). Sleep-related eating disorder is a parasomnia described in the third edition of the International Classification of Sleep Disorders (American Academy of Sleep Medicine, 2014). It consists of periods of involuntary eating during the main sleep period. Persons with this parasomnia may eat nonfood items (e.g., shaving cream), inedible items (e.g., frozen foods), or odd combinations of food items (e.g., salt and sugar sandwich), and they may injure themselves obtaining or preparing food. Sleep-related eating disorder is associated with other primary sleep disorders and may be treated pharmacologically. Psychotherapeutic approaches are not generally effective because there is little or no awareness of the nocturnal eating behavioral while it is happening. Of note, some persons presenting for treatment have nocturnal eating episodes with awareness at times and have them without awareness at other times. Clinically, patients have presented reporting that they were sleepwalking during their eating episodes in the early years of their disorder but gained awareness over time. Clearly, NES and sleep-related eating disorder exist on a continuum, but more work is needed to understand their shared and unique pathophysiology.
Accurate diagnosis is critical to the delivery of appropriate care for NES. Multiple validated self-report measures and semistructured interviews have been developed for the assessment of NES symptoms, including the Night Eating Questionnaire (NEQ; Allison et al., 2008), a self-report screening measure; the Night Eating Syndrome History and Inventory (NESHI), a diagnostic interview that was developed as an interview companion to the NEQ (Lundgren, Allison, Vinai, & Gluck, 2012); and the Night Eating Symptom Scale (NESS), a self-report measure based on the NEQ used during treatment to assess symptom change in the previous week (Lundgren, Allison, Vinai, et al., 2012). The Night Eating Diagnostic Scale (NEDS) is another self-report measure designed to be face valid in assessing each NES diagnostic criterion (Lundgren, Allison, Vinai, et al., 2012). In addition, a single item of the Eating Disorder Examination (Fairburn, Cooper, & O’Connor, (p. 208) 2008), a semistructured interview that is considered the “gold standard” in eating disorder assessment, assesses for the presence of nocturnal ingestions.
In light of changing diagnostic criteria and inconsistent assessment techniques, NES prevalence estimates in large community samples range widely. The first estimate was 1.5% in adults (Rand, Macgregor, & Stunkard, 1997). Evening and nighttime food intake data from the Continuing Survey of Food Intakes by Individuals and the National Health and Nutrition Examination Survey–III yielded a wide range of prevalence estimates between 9% and 36% of adults, depending on the time cut points used (Striegel-Moore, Franko, Thompson, Affenito, & Kraemer, 2006). Data from the Swedish Twin Study of Adults: Genes and Environment yielded estimates between 1.7% and 4.6%, depending on the stringency of criteria used (Lundgren, Allison, Stunkard, et al., 2012). Recently, in a large study of college students throughout the United States, NES prevalence was estimated to be 4.2%, and it was estimated to be 2.9% when any binge eating was excluded (Runfola, Allison, Hardy, Lock, & Peebles, 2014). A large study of German adolescents and adults (aged 14–85 years) estimated NES prevalence to be 1.1% (de Zwaan, Müller, Allison, Brähler, & Hilbert, 2014), whereas prevalence of NES in Germany had previously been estimated to be 1.1% in children but 5.8% in mothers and 4.5% in fathers (Lamerz et al., 2005). The point prevalence of NES in psychiatric outpatients was estimated to be between 12.3% and 22.4% (Lundgren et al., 2006; Saraçlı et al., 2015), and in patients with type 2 diabetes it was estimated to be 3.8% (Allison et al., 2007) and 7% (Hood, Reutrakul, & Crowley, 2014). Thus, depending on the population and criteria used, prevalence estimates of NES range widely from 1.1% to 36%.
Clinical Case Example
A recent case treated in the first author’s clinic illustrates typical NES symptom presentation. “Bob” was a successful, intelligent business man who seemed to have everything going for him. He presented for treatment saying that he had had many successes in life and had overcome many struggles, but he could not seem to stop his night eating. Bob recounted that he had been abused as a child by his father, who had alcohol use disorder, but he denied any symptoms of posttraumatic stress disorder. Starting at approximately the same time as this abuse, Bob would wake during the night, go to the kitchen, and have a snack. The house was quiet, and it was a time when he could relax and enjoy his eating without other concerns. As he matured, Bob became an athlete and was “known for [his] eating.” He could eat large amounts and was very active, so at the time he viewed his ongoing night eating as aiding his attempt to keep his body “fueled for activity.” After he stopped playing sports competitively, he started gaining weight (p. 209) and, like his father, developed alcohol use disorder. Bob recounted that he was able to stop his drinking when he realized the impact it was having on him and his family, but despite repeated attempts, he was not able to stop his night eating.
Bob had tried many different approaches, including sleeping in an outbuilding on his property for up to 3 months at a time so he would not have access to food during the night. This intervention was initially successful, but when he would return to sleeping in his bedroom, the night eating resumed. As disciplined as he could be with sports and his business, he could not seem to overcome the urge to eat during the night, and so it continued one to three times every night. Every morning he would wake and exercise before starting his workday, and he tried to eat regularly during the day despite lack of a morning appetite, but the pattern persisted. Although he could abstain completely from alcohol to treat his alcohol use disorder, he could not stop eating altogether or having food in his home, particularly when living with others.
Evidence-Based Treatment Approaches for Night Eating Syndrome
Several trials have investigated pharmacological treatments for NES symptoms, particularly the use of selective serotonin reuptake inhibitors (SSRIs). One case series of paroxetine or fluvoxamine (Miyaoka et al., 2003), two open-label trials of sertraline (O’Reardon, Stunkard, & Allison, 2004; Stunkard et al., 2006), and one randomized, placebo-controlled trial of sertraline (O’Reardon et al., 2006) indicated that NES can be successfully treated with SSRIs. Dosing of sertraline ranged from 50 to 200 mg, with patients responding at a mode of 150 mg in the randomized controlled trial (O’Reardon et al., 2006). The results of both a 12-week, randomized, placebo-controlled trial of escitalopram (Vander Wal, Gang, Griffing, & Gadde, 2012), another SSRI, and a 12-week open-label trial of escitalopram (Allison et al., 2013) indicated improvements in NES symptoms, but these improvements were not statistically significantly different from those found in the placebo group in the controlled trial (Vander Wal et al., 2012). Finally, case studies suggest that topiramate, an antiepileptic medication that has been used to treat BN and BED in off-label use, also seems promising in the treatment of NES (Winkelman, 2003), but controlled trials are needed in this population.
Behavioral Interventions for Night Eating Syndrome
Early psychotherapeutic approaches for NES symptoms among obese individuals were initially psychodynamically oriented and focused on stress reduction (Stunkard, 1976), followed by behavioral interventions published for two cases (p. 210) with mixed results (Coates, 1978; Williamson, Lawson, Bennett, & Hinz, 1989). Since these initial case studies, two main behavioral treatments have been investigated: progressive muscle relaxation and behavioral weight loss. Only two controlled trials of progressive muscle relaxation for NES have been published. Based on the finding of high levels of stress associated with NES, one study compared a group that received a behavioral stress management intervention—a 1-week, abbreviated progressive muscle relaxation therapy (APMRT; 20 minutes per night)—to a control group that quietly sat for a matched amount of time (Pawlow, O’Neil, & Malcolm, 2003). The APMRT group reported significantly decreased evening appetite and increased morning appetite, in addition to lower levels of stress, fatigue, and anxiety. Decreases in nocturnal ingestion intake and increases in breakfast intake were not statistically significant, but effect sizes for these differences were large. A recent pilot study reported that a brief education session (meant to serve as a control), brief PMR training and practice, and brief PMR training plus exercise instruction all resulted in significant reductions in symptoms of anxiety, depression, stress, and NES (Vander Wal, Maraldo, Vercellone, & Gagne, 2015); however, groups that received PMR interventions showed the greatest reductions in evening hyperphagia. Results from these brief, small trials indicate that further investigation of the efficacy of PMR for NES symptoms is warranted.
Only one study has examined the effects of behavioral weight loss treatment on NES symptoms. Dalle Grave, Calugi, Ruocco, and Marchesini (2011) investigated a 21-day inpatient treatment for obese individuals with or without NES followed by either outpatient treatment with an obesity specialist for 62% of the sample or no treatment for the remaining 38%. Equal proportions of night eaters received ongoing care after discharge. The inpatient program included a low-calorie diet and a regular pattern of eating, daily exercise, and psychoeducational group therapy focusing on behavioral weight loss strategies. This intervention resulted in a reduction in body mass index (BMI) across all individuals: Those with NES (n = 32) lost 1.9 kg/m2, on average, whereas those without NES (n = 68) lost 1.5 kg/m2 in the inpatient treatment; however, these reductions in BMI were not statistically significantly different. Similarly, at 6-month follow-up, the percentage of weight loss from baseline weight among those with NES (6.4%) and those without NES (8.2%) did not differ. The authors report that there were no differences in BMI reduction at 6 months for those who continued night eating as opposed to those who had discontinued these behaviors. Although behavioral weight loss did not have a differential impact on weight loss among those with or without NES, only 27.6% of individuals who originally met criteria for NES retained the diagnosis at 6-month follow-up. In addition, 62.1% of those with NES at baseline reported that they had been abstinent from night eating for 3 months. This may have been influenced by lack of availability of food during the inpatient stay, much as Bob’s symptoms remitted when he slept outside of his main home for 3 months.
The results of the study by Dalle Grave et al. (2011) suggest that the behavioral weight loss treatment effectively controlled night eating symptoms for a large proportion of those presenting with an NES diagnosis, although these results should be replicated in an outpatient setting, and long-term follow-up of maintenance (p. 211) of the treatment effects should be reported. Behavioral weight loss treatment has also been shown to reduce both binge-eating episode frequency and weight in clients with BED (Munsch, Meyer, & Biedert, 2012), suggesting that the behavior modification approaches contained in structured behavioral weight loss programs impact disordered eating related to overweight and obesity, such as night eating and binge eating.
Although the active ingredients of behavioral weight loss key to reducing night eating symptoms cannot be identified in the investigation of Dalle Grave and colleagues (2011), two elements of the treatment seem likely candidates. First, structured daytime food intake in behavioral weight loss may address the delayed pattern of eating characteristic of NES. Indeed, Boston, Moate, Allison, Lundgren, and Stunkard (2008) showed that individuals with NES do not report scheduled, consistent mealtimes over the 24-hour day as control participants do, and this may drive night eating behaviors. Self-monitoring of food intake is the second likely key element of behavioral weight loss approaches in the treatment of NES. Just as self-monitoring is generally a strong, if not the strongest, predictor of successful weight loss (Wilde & Garvin, 2007), it also may promote increased awareness of the impact of night eating episodes on weight and may help clients re-evaluate their drive to eat and observe patterns in their eating behaviors.
Cognitive–Behavioral Therapy for Night Eating Syndrome
Theoretical Basis and Treatment Techniques
The success of several behaviorally focused interventions for NES suggests the conflict between the normal boundaries of sleep and the abnormal schedule of food intake characteristic of NES often contributes to the development of faulty cognitions about the function of eating at night or during nocturnal ingestions (Allison, Stunkard, & Thier, 2004). These include a belief that one needs to eat to resume sleep, thoughts about being incapable of avoiding eating at night, and thoughts about needing to eat to alleviate anxiety or agitation in the evening. As mentioned previously, this belief in the need to eat to fall asleep seems to represent an important differential diagnostic indicator between BED and NES (Vinai et al., 2014) and possibly between insomnia and NES.
Cognitive–behavioral therapy (CBT) for NES (Allison, 2012; Allison, Lundgren, Moore, O’Reardon, & Stunkard, 2010) therefore integrates behavioral interventions with cognitive techniques standard in CBT to address these seemingly integral distorted thoughts. This includes the use of dysfunctional thought records, developed by Beck and colleagues (Beck, Rush, Shaw, & Emery, 1979), on which clients record situations, resulting thoughts, emotions, behavioral outcomes, and potential alternative thoughts. This examination of distorted thoughts is complemented in CBT for NES by stimulus control interventions to help clients test the validity of their thoughts (e.g., of the inevitability of their night eating or their (p. 212) inability to resume sleep without eating) via behavioral experimentation. This identification of underlying automatic thoughts and the examination of environmental cues and emotions associated with night eating permit functional analysis of night eating behaviors. Other standard elements of CBT as conceived by Beck et al., including Socratic questioning, the “downward arrow” technique to identify core beliefs, and collaborative empiricism, are employed.
Elements of CBT for insomnia (CBT-I), which has been shown to be highly effective in the treatment of insomnia, also served as a theoretical framework for the development of CBT for NES. Components of CBT-I, such as improving sleep hygiene and standardizing bedtime and morning awakening time (Perlis et al., 2010), represent important elements of CBT for NES.
As is standard in most psychotherapeutic interventions, rapport-building and early investment in the therapeutic alliance are essential to CBT for NES. These more basic aspects of treatment may be particularly critical in this intervention because the workload of this therapy is high, and readiness for such involvement on the part of the client seems crucial for preventing treatment dropout.
CBT for NES occurs in three basic stages and consists of 10, 1-hour sessions (Allison, 2012). These sessions initially occur on a weekly basis, and the final 2 sessions are scheduled for every other week.
Before beginning treatment, a structured assessment of current NES symptoms is recommended. This may include the use of validated NES measures such as the NEQ (Allison et al., 2008) and the NESHI (Lundgren, Allison, Vinai, et al., 2012). In addition, assessment of potential comorbid disorders that would trump the treatment of NES, including severe depression, suicidal ideation, and anxiety disorders, should be completed before initiation of CBT for NES.
During the first stage of treatment, the therapist focuses on development of rapport with the client, psychoeducation about night eating, and review of the CBT rationale. Client homework includes self-monitoring of behaviors, completion of thought records, and behavioral experimentation. When night eating episodes occur, behavioral chain analyses are conducted, first collaboratively with the therapist in session and then for homework, to help identify cognitive and behavioral intervention targets. The layout of one’s home is explored, and the typical route one takes while night eating is examined. Assignments for decreasing nocturnal ingestions could include placing signs on doors, in the bathroom, and on the refrigerator with statements meaningful to clients that would help them remember their daytime intentions for not eating, thereby disrupting the automation of (p. 213) the typical nighttime eating routine. Other strategies could include placing barriers along the path to the kitchen, removing food or locking cabinets to limit access to preferred night-eating foods, and completing self-monitoring forms to raise awareness and identify intervention targets (Allison, 2012). In addition to reminding patients of their intentions for not wanting to eat at night, these barriers create a pause between waking and eating, giving patients more time to engage in thought restructuring and question whether the effort to obtain the food is consistent with their health behavior goals.
We implemented these strategies in treatment with Bob to break the association between eating upon awakening when he slept in his own bedroom. He placed furniture in front of the kitchen entry, piled up pillows on the chair that he typically sat in to eat during the night, and placed reminder signs along the way to the kitchen from his room. He also kept a bottle of water beside his bed and in the bathroom. All of these cues were present in an effort to help him challenge his assumptions that he could not resist the urge to eat and that he could not fall back to sleep without eating. He also worked with our nutritionist to increase the variety of nutrients he was receiving and to schedule his meals and snacks more regularly throughout the day.
Because similar stimulus control and structured eating pattern interventions are shared by this CBT for NES and by standard behavioral weight loss treatment, weight loss is included in CBT for NES as a goal for those who wish to reduce their weight. For these individuals, caloric monitoring is included with self-monitoring of night eating behaviors and sleep patterns (time of sleep onset, time and duration of nocturnal awakenings, and morning rise time). Bob also tracked his intake with an Internet-based application, which the therapist and nutritionist could review at each session.
In the second stage of treatment, the therapist and client work collaboratively to identify thematic patterns in self-monitoring that are used to tailor treatment. Cognitive restructuring is taught and practiced, and clients engage in behavioral experiments and stimulus control to challenge automatic thoughts as they are identified. This includes experimentation with how long patients are able to engage in an alternate, quiet task (e.g., in 10-minute increments) while tolerating their drive to eat. The longer they are able to engage in a distracting activity, such as listening to music, deep breathing, or reading in low light, the better able they are to test the assumption that they will not be able to resume sleep without eating. Breakfast is also added to the client’s pattern of eating. For clients with comorbid major depression, cognitive distortions beyond the bounds of night eating are also addressed in this second stage of treatment because these automatic thoughts, along with those related to anxiety or stress, may serve as catalysts for night eating (Allison et al., 2004). If appropriate, alternative strategies to night eating, including PMR and deep breathing exercises, are introduced in these Stage 2 sessions. Additional elements of sleep hygiene and physical activity are (p. 214) also addressed in this stage because these are thought to promote sounder sleep and improve weight and stress management.
Bob was already exercising most days when he woke in the morning, but we were able to use PMR and other quiet activities during the night to prevent his going to the kitchen and help him ride out the initial discomfort associated with urges to eat. We also used thought records to address his ongoing stressors, both at work and at home, so that he was not ruminating on these issues during the night when he awoke.
For the final two sessions, which comprise Stage 3 of CBT for NES, treatment transitions to biweekly. These sessions include summarizing and reflecting on progress and bolstering the client’s confidence and sense of self-efficacy to continue on his or her own with successful changes. These final sessions also focus on relapse prevention through prediction of future challenges and anticipatory problem-solving.
Evidence in Support of Cognitive–Behavioral Therapy for Night Eating Syndrome
To date, only one empirical investigation of CBT for NES has been published. This pilot study of the 10-session CBT for NES protocol described previously included 25 individuals with NES (Allison, Lundgren, Moore, et al., 2010). After treatment, the number of nocturnal ingestions decreased significantly, as did calories from nocturnal ingestions (from 8.7 to 2.6 per week). There was a statistically nonsignificant decrease, from 35% to 24.9%, in the proportion of calories consumed after dinner. Total daily intake, number of awakenings, and NESS total scores all decreased significantly. Participants lost a significant amount of weight because this was also a target of treatment for most clients, and depression scores were reduced. The amount of food consumed during nocturnal ingestions was reduced significantly, but the quantity consumed before bedtime was not significantly affected. From the perspective of clinical significance, the percentage of intake consumed after dinner decreased after treatment to a level just below the diagnostic boundary for NES. This effect is largely attributable to the reduction in nocturnal ingestions. Compared to prior investigations, outcome results are similar to those of the aforementioned sertraline trial (O’Reardon, Stunkard, et al., 2004). The results also suggest that the effects of CBT are greater than those of PMR alone (Pawlow et al., 2003).
Phototherapy: Another Promising Treatment
In addition to the treatments examined previously, phototherapy, or exposure to certain wavelengths of light via a light-emitting device for prescribed amounts of (p. 215) time, has been investigated for the treatment of NES. Traditionally used to treat sleep and mood disorders, phototherapy’s effects on melatonin, a key regulator of circadian rhythm, prompted trials of phototherapy as a potential treatment for NES, which has been conceptualized by some as a disorder of delayed circadian rhythm. Phototherapy has demonstrated initial effectiveness for NES in two case studies and an open-label pilot trial. The first case, an obese woman with comorbid nonseasonal major depressive disorder who was also taking paroxetine, remitted from NES after 14 days of daily phototherapy (Friedman, Even, Dardennes, & Guelfi, 2002). This case study followed a “BAB” design in which a no-treatment phase (A phase) followed the initial delivery of treatment (B phase), followed by the reintroduction to treatment (second B phase). The authors report that the client became symptomatic after discontinuation of phototherapy and remitted once more after 12 additional days of phototherapy. The second case, a normal-weight male, remitted from both nonseasonal major depressive disorder and NES following 14 sessions of daily phototherapy (Friedman, Even, Dardennes, & Guelfi, 2004). In an open-label pilot trial of 2 weeks of daily bright light therapy in 15 adults with NES, symptoms of depression, NES, and sleep disturbance all improved from pre- to post-treatment (McCune & Lundgren, 2015). Although these very preliminary findings are promising, they require randomized controlled trials to confirm the efficacy of phototherapy for the treatment of NES.
The Impact of Weight Status on Night Eating Symptom Expression and Treatment Response
In addition to consideration of comorbidities in treatment planning for individuals with NES, research indicates that weight status represents an important variable both in the expression of night eating symptoms and in response to NES treatment. Marshall, Allison, O’Reardon, Birketvedt, and Stunkard (2004) were the first to show that compared to obese individuals with NES, individuals at a normal body weight with NES reported more severe nocturnal eating symptoms, including more awakenings, more cravings when up at night, and more nocturnal ingestions, as measured by the NEQ. Subsequently, Lundgren and colleagues (2008) further characterized normal-weight individuals with NES (n = 19), reporting that they consumed 50% of their daily caloric intake after dinner and experienced 13 awakenings (getting out of bed) and 10 nocturnal ingestions per week, on average. These figures are higher than those reported among overweight and obese individuals with NES, who have been reported in one sample (n = 46) to consume 35% of their intake after dinner and experience approximately 11 awakenings and 8 nocturnal ingestions per week (O’Reardon, Ringel, et al., 2004).
Findings that normal-weight individuals with NES eat a higher percentage of their intake at night than do overweight and obese persons may seem counterintuitive. One potential explanation may be related to more active daytime intake restriction and exercise in individuals of normal weight with NES to counteract (p. 216) nightly caloric intake. This may result in the first meal of the day occurring much later than that for overweight and obese persons with NES, who report eating more calories generally throughout the day. Increased dietary restriction during the day in the normal-weight group may therefore exert an increased biological pressure to eat, which may in turn trigger more frequent nocturnal ingestions, thereby reinforcing the night eating cycle.
Treatment recommendations for individuals with NES who are normal weight may also differ from those for overweight and obese clients with NES. Because of the more extreme pattern that includes dietary restriction during the day, normal-weight clients with NES may fear weight gain as a result of NES treatment. This may preclude normal-weight clients from adopting a pattern of eating that includes earlier meals for fear that they will be eating all day and all night, thus interfering with treatment adherence. The investigation by Allison and colleagues (2010) indicated that this was not the case: Normal-weight participants did not gain weight during this pilot study of CBT. Of note, behavioral weight loss components, including calorie counting, were omitted from the CBT treatment of normal-weight participants. Interventions with normal-weight individuals with NES may require increased focus on weight gain-related fears. Furthermore, normal-weight participants have been found to demonstrate reductions in the percentage of food intake after dinner and their number of nocturnal ingestions per week at a similar rate as overweight and obese participants receiving CBT for NES, but they start and end with higher symptom levels as a result of this baseline difference. Longer term treatment for this normal-weight group may be warranted, given the higher level of symptom severity.
Nonstandardized and frequently changing diagnostic definitions of NES have challenged the study of the treatment of the disorder. Initial investigations of SSRIs, phototherapy, and behavioral and cognitive–behavioral interventions for NES have all demonstrated some degree of success in reducing or eliminating night eating. Despite promising evidence from initial trials, further research investigating efficacious treatments for NES is needed. Randomized controlled trials of CBT for NES, alone and in combination with psychotropic medications, are also needed. Furthermore, studies that include larger sample sizes of individuals who are normal weight, overweight, and obese are necessary to parse the relative benefits of CBT for NES across weight classes. In addition to randomized controlled studies comparing CBT with other treatment modalities, dismantling studies to identify the active ingredients in this treatment are warranted. Although extant evidence suggests that 10 sessions of CBT produce promising outcomes, longer durations of treatment should be tested because there have been no long-term studies examining the durability of this treatment generally or the duration of remission in treatment responders. Finally, the effect of psychiatric comorbidities on treatment outcome is unknown, and because of the high rate of overlap between NES and other eating, mood, anxiety, and substance use disorders, structured investigations of the impact of comorbidity on treatment response are needed.
(p. 217) Author Note
The following resources may prove helpful to clinicians treating patients with night eating:
Allison, K. C. (2012). Cognitive–behavioral therapy manual for night eating syndrome. In J. D. Lundgren, K. C. Allison, & A. J. Stunkard (Eds.), Night eating syndrome: Research, assessment, and treatment. New York, NY: Guilford. This is a comprehensive therapist manual for the 10-session CBT protocol described previously, and it includes handouts for the intervention.Find this resource:
Allison, K. C., Stunkard, A. J., & Thier, S. L. (2004). Overcoming the night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger. This is a self-help guide for NES.Find this resource:
Lundgren, J. D., Allison, K. C., Vinai, P., & Gluck, M. E. (2012). Assessment instruments for night eating syndrome. In J. D. Lundgren, K. C. Allison, & A. J. Stunkard (Eds.), Night eating syndrome: Research, assessment, and treatment. New York, NY: Guilford. This book chapter includes measures that assess NES diagnosis and severity.Find this resource:
Allison, K. C. (2012). Cognitive–behavioral therapy manual for night eating syndrome. In J. D. Lundgren, K. C. Allison, & A. J. Stunkard (Eds.), Night eating syndrome: Research, assessment, and treatment. New York, NY: Guilford.Find this resource:
Allison, K. C., Crow, S. J., Reeves, R. R., West, D. S., Foreyt, J. P., Dilillo, V. G., … Stunkard, A. J. (2007). Binge eating disorder and night eating syndrome in adults with type 2 diabetes. Obesity (Silver Spring), 15(5), 1287–1293.Find this resource:
Allison, K. C., Grilo, C. M., Masheb, R. M., & Stunkard, A. J. (2005). Binge eating disorder and night eating syndrome: A comparative study of disordered eating. Journal of Consulting & Clinical Psychology, 73(6), 1107–1115.Find this resource:
Allison, K. C., Lundgren, J. D., Moore, R. H., O’Reardon, J. P., & Stunkard, A. J. (2010). Cognitive behavior therapy for night eating syndrome: A pilot study. American Journal of Psychotherapy, 64(1), 91–106.Find this resource:
Allison, K. C., Lundgren, J. D., O’Reardon, J. P., Geliebter, A., Gluck, M. E., Vinai, P., … Stunkard, A. J. (2010). Proposed diagnostic criteria for night eating syndrome. International Journal of Eating Disorders, 43, 241–247.Find this resource:
(p. 218) Allison, K. C., Lundgren, J. D., O’Reardon, J. P., Martino, N. S., Sarwer, D. B., Wadden, T. A., … Stunkard, A. J. (2008). The Night Eating Questionnaire (NEQ): Psychometric properties of a measure of severity of the night eating syndrome. Eating Behaviors, 9(1), 62–72.Find this resource:
Allison, K. C., Studt, S. K., Berkowitz, R. I., Hesson, L. A., Moore, R. H., Dubroff, J. G., … Stunkard, A. J. (2013). An open-label efficacy trial of escitalopram for night eating syndrome. Eating Behaviors, 14(2), 199–203.Find this resource:
Allison, K. C., Stunkard, A. J., & Thier, S. L. (2004). Overcoming the night eating syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger.Find this resource:
American Academy of Sleep Medicine. (2014). International classification of sleep disorders: Diagnostic and coding manual (3d ed.). Westchester, IL: Author.Find this resource:
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.Find this resource:
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.Find this resource:
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford.Find this resource:
Boston, R. C., Moate, P. J., Allison, K. C., Lundgren, J. D., & Stunkard, A. J. (2008). Modeling circadian rhythms of food intake by means of parametric deconvolution: Results from studies of the night eating syndrome. American Journal of Clinical Nutrition, 87(6), 1672–1677.Find this resource:
Coates, T. J. (1978). Successive self-management strategies towards coping with night eating. Journal of Behavior Therapy and Experimental Psychiatry, 9, 181–183.Find this resource:
Dalle Grave, R., Calugi, S., Ruocco, A., & Marchesini, G. (2011). Night eating syndrome and weight loss outcome in obese patients. International Journal of Eating Disorders, 44(2), 150–156.Find this resource:
de Zwaan, M., Müller, A., Allison, K. C., Brähler, E., & Hilbert, A. (2014). Prevalence and correlates of night eating in the German general population. PLoS One, 9(5), e97667.Find this resource:
Fairburn, C. G., Cooper, Z., & O’Connor, M. (2008). Eating disorder examination (Edition 16.0D). In C. G. Fairburn (Ed.), Cognitive behavior therapy and eating disorders. New York, NY: Guilford.Find this resource:
Fischer, S., Meyer, A. H., Hermann, E., Tuch, A., & Munsch, S. (2012). Night eating syndrome in young adults: Delineation from other eating disorders and clinical significance. Psychiatry Research, 200(2-3), 494–501.Find this resource:
Friedman, S., Even, C., Dardennes, R., & Guelfi, J. D. (2004). Light therapy, nonseasonal depression, and night eating syndrome. Canadian Journal of Psychiatry, 49(11), 790.Find this resource:
Greeno, C. G., Wing, R. R., & Marcus, M. D. (1995). Nocturnal eating in binge eating disorder and matched-weight controls. International Journal of Eating Disorders, 18, 343–349.Find this resource:
Hood, M. M., Reutrakul, S., & Crowley, S. J. (2014). Night eating in patients with type 2 diabetes: Associations with glycemic control, eating patterns, sleep, and mood. Appetite, 79, 91–96.Find this resource:
Howell, M. J., & Schenck, C. H. (2009). Treatment of nocturnal eating disorders. Current Treatment Options in Neurology, 11(5), 333–339.Find this resource:
Lamerz, A., Kuepper-Nybelen, J., Bruning, N., Wehle, C., Trost-Brinkhues, G., Brenner, H., … Herpertz-Dahlmann, B. (2005). Prevalence of obesity, binge eating, and night eating in a cross-sectional field survey of 6-year-old children and their parents in a German urban population. Journal of Child Psychology and Psychiatry, 46(4), 385–393.Find this resource:
(p. 219) Lundgren, J. D., Allison, K. C., Crow, S., O’Reardon, J. P., Berg, K. C., Galbraith, J., … Stunkard, A. J. (2006). Prevalence of the night eating syndrome in a psychiatric population. American Journal of Psychiatry, 163(1), 156–158.Find this resource:
Lundgren, J. D., Allison, K. C., O’Reardon, J. P., & Stunkard, A. J. (2008). A descriptive study of non-obese persons with night eating syndrome and a weight-matched comparison group. Eating Behaviors, 9(3), 343–351.Find this resource:
Lundgren, J. D., Allison, K. C., Stunkard, A. J., Bulik, C. M., Thornton, L. M., Karin Lindroos, A., & Rasmussen, F. (2012). Lifetime medical and psychiatric comorbidity of night eating behavior in the Swedish Twin Study of Adults: Genes and Environment (STAGE). Psychiatry Research, 199(2), 145–149.Find this resource:
Lundgren, J. D., Allison, K. C., Vinai, P., & Gluck, M. E. (2012). Assessment instruments for night eating syndrome. In J. D. Lundgren, K. C. Allison, & A. J. Stunkard (Eds.), Night eating syndrome: Research, assessment, and treatment. New York, NY: Guilford.Find this resource:
Lundgren, J. D., McCune, A., Spresser, C., Harkins, P., Zolton, L., & Mandal, K. (2011). Night eating patterns of individuals with eating disorders: Implications for conceptualizing the night eating syndrome. Psychiatry Research, 186(1), 103–108.Find this resource:
Lundgren, J. D., Shapiro, J. R., & Bulik, C. M. (2008). Night eating patterns of patients with bulimia nervosa: A preliminary report. Eating and Weight Disorders, 13(4), 171–175.Find this resource:
Marshall, H. M., Allison, K. C., O’Reardon, J. P., Birketvedt, G., & Stunkard, A. J. (2004). Night eating syndrome among nonobese persons. International Journal of Eating Disorders, 35(2), 217–222.Find this resource:
McCune, A. M., & Lundgren, J. D. (2015). Bright light therapy for the treatment of night eating syndrome: A pilot study. Psychiatry Research, 229(1-2), 577–579.Find this resource:
Miyaoka, T., Yasukawa, R., Tsubouchi, K., Miura, S., Shimizu, Y., Sukegawa, T., … Horiguchi, J. (2003). Successful treatment of nocturnal eating/drinking syndrome with selective serotonin reuptake inhibitors. International Clinical Psychopharmacology, 18(3), 175–177.Find this resource:
Munsch, S., Meyer, A. H., & Biedert, E. (2012). Efficacy and predictors of long-term treatment success for cognitive–behavioral treatment and behavioral weight-loss treatment in overweight individuals with binge eating disorder. Behaviour Research and Therapy, 50(12), 775–785.Find this resource:
O’Reardon, J. P., Allison, K. C., Martino, N. S., Lundgren, J. D., Heo, M., & Stunkard, A. J. (2006). A randomized, placebo-controlled trial of sertraline in the treatment of night eating syndrome. American Journal of Psychiatry, 163(5), 893–898.Find this resource:
O’Reardon, J. P., Ringel, B. L., Dinges, D. F., Allison, K. C., Rogers, N. S., Martino, N. S., & Stunkard, A. J. (2004). Circadian eating and sleeping patterns in the night eating syndrome. Obesity Research, 12, 1789–1796.Find this resource:
O’Reardon, J. P., Stunkard, A. J., & Allison, K. C. (2004). A clinical trial of sertraline in the treatment of night eating syndrome. International Journal of Eating Disorders, 35(1), 16–26.Find this resource:
Pawlow, L. A., O’Neil, P. M., & Malcolm, R. J. (2003). Night eating syndrome: Effects of brief relaxation training on stress, mood, hunger, and eating patterns. International Journal of Obesity and Related Metabolic Disorders, 27(8), 970–978.Find this resource:
Perlis, M. L., Smith, M. T., Jungquist, C., Nowakowski, S., Orff, H., & Soeffing, J. (2010). Cognitive–behavioral therapy for insomnia. In H. P. Attarian & C. Schuman (Eds.), Clinical handbook of insomnia (pp. 281–296). New York, NY: Humana Press.Find this resource:
(p. 220) Rand, C. S. W., Macgregor, A. M. C., & Stunkard, A. J. (1997). The night eating syndrome in the general population and among postoperative obesity surgery patients. International Journal of Eating Disorders, 22(1), 65–69.Find this resource:
Runfola, C. D., Allison, K. C., Hardy, K. K., Lock, J., & Peebles, R. (2014). Prevalence and clinical significance of night eating syndrome in university students. Journal of Adolescent Health, 55(1), 41–48.Find this resource:
Saraçlı, Ö., Atasoy, N., Akdemir, A., Güriz, O., Konuk, N., Sevinçer, G. M., … Atik, L. (2015). The prevalence and clinical features of the night eating syndrome in psychiatric out-patient population. Comprehensive Psychiatry, 57, 79–84.Find this resource:
Striegel-Moore, R. H., Franko, D. L., & Garcia, J. (2009). The validity and clinical utility of night eating syndrome. International Journal of Eating Disorders, 42(8), 720–738.Find this resource:
Striegel-Moore, R. H., Franko, D. L., May, A., Ach, E., Thompson, D., & Hook, J. M. (2006). Should night eating syndrome be included in the DSM? International Journal of Eating Disorders, 39(7), 544–549.Find this resource:
Striegel-Moore, R. H., Franko, D. L., Thompson, D., Affenito, S., & Kraemer, H. C. (2006). Night eating: Prevalence and demographic correlates. Obesity, 14(1), 139–147.Find this resource:
Stunkard, A. J. (1976). The pain of obesity. Palo Alto, CA: Bull Publishing.Find this resource:
Stunkard, A. J., Allison, K. C., Lundgren, J. D., Martino, N. S., Heo, M., Etemad, B., & O’Reardon, J. P. (2006). A paradigm for facilitating pharmacotherapy at a distance: Sertraline treatment of the night eating syndrome. Journal of Clinical Psychiatry, 67(10), 1568–1572.Find this resource:
Stunkard, A. J., Berkowitz, R., Wadden, T., Tanrikut, C., Reiss, E., & Young, L. (1996). Binge eating disorder and the night-eating syndrome. International Journal of Obesity and Related Metabolic Disorders, 20, 1–6.Find this resource:
Stunkard, A. J., Grace, W. J., & Wolff, H. G. (1955). The night-eating syndrome: A pattern of food intake among certain obese patients. American Journal of Medicine, 19, 78–86.Find this resource:
Tzischinsky, O., & Latzer, Y. (2004). Nocturnal eating prevalence, features and night sleep among binge eating disorders and bulimia nervosa patients in Israel. European Eating Disorders Review, 12, 101–109.Find this resource:
Vander Wal, J. S., Gang, C. H., Griffing, G. T., & Gadde, K. M. (2012). Escitalopram for treatment of night eating syndrome: A 12-week, randomized, placebo-controlled trial. Journal of Clinical Psychopharmacology, 32(3), 341–345.Find this resource:
Vander Wal, J. S., Maraldo, T. M., Vercellone, A. C., & Gagne, D. A. (2015). Education, progressive muscle relaxation therapy, and exercise for the treatment of night eating syndrome: A pilot study. Appetite, 89, 136–144.Find this resource:
Vinai, P., Cardetti, S., Studt, S., Carpegna, G., Ferrato, N., Vallauri, P., … Manconi, M. (2014). Clinical validity of the descriptor “presence of a belief that one must eat in order to get to sleep” in diagnosing the night eating syndrome. Appetite, 75, 46–48.Find this resource:
Vinai, P., Provini, F., Antelmi, E., Marcatelli, M., Cardetti, S., Vinai, L., … Allison, K. C. (2015). Alexithymia is not related to severity of night eating behavior: A useful distinction from other eating disorders. Eating Behaviors, 17, 94–98.Find this resource:
Wilde, M. H., & Garvin, S. (2007). A concept analysis of self-monitoring. Journal of Advanced Nursing, 57(3), 339–350.Find this resource:
Williamson, D. A., Lawson, O. D., Bennett, S. M., & Hinz, L. (1989). Behavioral treatment of night bingeing and rumination in an adult case of bulimia nervosa. Journal of Behavior Therapy and Experimental Psychiatry, 20(1), 73–77.Find this resource:
Winkelman, J. W. (2003). Treatment of nocturnal eating syndrome and sleep-related eating disorder with topiramate. Sleep Medicine, 4(3), 243–246.Find this resource: