Kendra is a 28-year-old former US Army nurse, honorably discharged after 17 months of active duty in Afghanistan following a knee injury requiring surgery and extensive rehabilitation, who is coming for her first appointment with Dr. Levine, a primary care doctor in an ambulatory care clinic. Kendra reports having a history of migraines, but otherwise is not aware of any major medical problems. She admits that it has been 2 years since she is come to see a physician: “I’m embarrassed to say it, but I haven’t been taking great care of myself.” She admits that while she was very active before and during her military days, after returning home from the service and completing her allotted six weeks of physical therapy sessions, she stopped exercising and started eating more “junk”. She does not know how much weight she has gained, but says she has started to wear oversized clothes without dress sizes because “I don’t really want to know my size.” She says she is uncomfortable with how she looks. She states that she lives near her parents and her older sister (who is married with children) and reports not having many other friends. She describes feeling acutely nervous when she imagines meeting new people or socializing in group settings, saying that she is uncomfortable with how she looks: “I’ve always been terrible at small talk—I just can’t do it and I freeze up.” She says that recently being around people other than her family has made her “want to go home and eat a bag of cookies,” but then she trails off and does not finish her thought.

Kendra reports that her knee injury was sustained while working in the field, attempting to recover and save a soldier who was wounded near a bomb-making compound. A comrade there with her detonated a mine while they were approaching the wounded soldier, and Kendra fell to her side after the explosion, twisting her knee and tearing her anterior cruciate ligament. She could not get up and saw her comrade unconscious and bleeding near her, unable to act and not knowing what to do. She then says to Dr. Levine that she would prefer to stop talking about the event as it is “easier for me to put stuff like that away.”

While writing his note later in the day, Dr. Levine had more questions about Kendra, and listed those he wanted to address in their next visit. He was curious to hear more about her eating habits, wondering what she meant about eating the cookies (was she describing binge-eating behavior?), as well as about her anxiety in social settings and the emotional consequences of her experiences in the military, including the day she was injured. He spoke to a psychiatrist colleague in the ambulatory care center, who also wondered whether Kendra might have a history of traumatic events other than the day of her injury, based on her comment about “putting stuff like that away”—had there been other experiences in her life “like that”?

Kendra fulfills diagnostic criteria for social anxiety disorder (SAD) and perhaps generalized anxiety disorder (GAD) . Dr. Levine strongly suspects an eating disorder, specifically binge eating disorder (BED) . He also wonders about trauma and an additional diagnosis of posttraumatic stress disorder (PTSD) .

Kendra’s presentation is typical for patients with BED [see Chap. 9 for further discussion of BED]. It may be more common than not for an individual with BED to have another co-occurring mental illness, with studies showing that two-thirds have received an anxiety disorder diagnosis, almost one-half have been diagnosed with a depressive or bipolar disorder, and nearly one-quarter have fulfilled criteria for a substance use disorder. Personality disorders are equally common, occurring in nearly one-third of patients diagnosed with BED; avoidant personality disorder is a particularly common one, which shares many features of anxiety disorders, notably SAD [1]. In fact, it is most often the other mental disorders that bring these patients to clinical attention, not the eating symptoms. As discussed in Chap. 9, lack of awareness about BED as a validated and treatable condition, as well as shame regarding eating symptoms, may limit help-seeking in individuals with binge-eating behaviors and full-syndrome BED. Even when they come to attention, they may preferentially discuss other symptoms, such as depressive or anxiety symptoms, for all of the same reasons. Clinicians, too, may not think to screen for disordered eating symptoms or—even if they suspect them—may not know how to ask. Recognizing that binge eating behavior may accompany various other psychiatric conditions may help to prompt the clinician to begin asking patients about their eating behaviors and may help to detect cases of BED and other feeding and eating disorders that would have remained undiagnosed. Detection, in turn, will open up the possibility for treatment.