Binge eating disorder (BED) is characterized by recurrent episodes of binge eating in the absence of inappropriate compensatory behaviors such as vomiting or excessive use of diuretics and laxatives. Currently, it falls under the category of Eating Disorder Not Otherwise Specified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). An individual with BED lacks control over his or her eating, rapidly consuming large quantities of food over an extremely short period of time. Commonly, they eat when not hungry and will continue to eat until they are uncomfortably full. They may eat alone out of embarrassment and disgust, experiencing depression and guilt over their eating patterns. The frequency of binge eating is at least twice a week, for 6 months or more.
BED affects 2% of the general population or 30% of obese patients in medical treatment. All eating disorders affect females more than males and perhaps 60% of BED patients are females. All socioeconomic classes and ethnic groups are affected. BED is distinct from anorexia nervosa (AN) and bulimia nervosa (BN) and rarely do patients with BED develop AN or BN. BED patients do not fixate on body shape or weight, are often overweight, and do not generally use vomiting, diuretics, or laxatives to control weight. Most patients with BED have physical complications of obesity such as hypertension, non-insulin-dependent diabetes mellitus, and menstrual disturbances. Patients with obesity and BED often become trapped in a cycle of desperately attempting to diet followed by losing control, binge eating, and gaining more weight.
Adopting a treatment approach with long-term focus on improved physical and psychological health could lead to behavioral changes and improved self-acceptance. The goals of treatment include cessation of binge eating, improved physical health mediated in part by weight loss, and reduction in psychological distress. Behavioral weight control, cognitive behavioral therapy, and interpersonal therapy are all advantageous. Behavioral weight control techniques include positive reinforcement of healthy eating, stimulus control by limiting exposure to unhealthy foods, and development of pleasurable alternatives to binge eating. These therapies reduce binge frequency and promote short-term weight loss in obese patients with BED. A variation to this approach is following a very low calorie diet with liquid nutritional supplements, but partial relapse during refeeding frequently occurs. Cognitive behavioral therapy (CBT) in group or individual therapy seeks to identify the thoughts, feelings, and circumstances leading to binge eating and to modify these by restructuring dysfunctional cognition. The specific focus is on examination of thoughts and feelings related to body image and in promotion of self-acceptance. Studies of CBT for BED have reported excellent shortterm binge reduction but variable deterioration over the long term and no significant weight loss. Interpersonal therapy seeks to identify the problems between individuals that contribute to maintenance of this maladaptive pattern. A substantial reduction in binge eating may initially occur but by 1 year, some symptoms often return. An alternative is a sequential treatment model consisting of 12 weeks of CBT followed by 24 weeks of group behavioral weight loss treatment and subsequent follow-up for 1 year. This model, advocated by the Stanford group, was successful in reducing binge eating and maintaining the response at 1 year. The New York State Psychiatric Institute also promoted a combination of group behavioral weight control program and close follow-up.
Pharmacological interventions include use of serotonin reuptake inhibitors like sertraline (Zoloft) and fluoxetine (Prozac), venlafaxine (Effexor), and tricyclic antidepressants. However, weight loss is usually a short-term effect and none of these medications have been Food and Drug Administration (FDA) approved for treatment of BED. A retrospective review of venlafaxine (75-300 mg/day) used in obese BED patients showed a decrease in binge eating severity and frequency with 5% weight loss in 43% of the patients. Fluoxetine is approved by the FDA for treatment of BN and has been noted to decrease binge eating. A 6-week placebo-controlled trial of fluoxetine (20-80 mg/day) in 60 outpatients reported a significant reduction in frequency of binge eating, body mass index, and severity of illness. A recent 14-week placebo-controlled study of topiramate (Topamax) (50-600 mg/day) in obese BED patients reported a reduction in binge frequency, body mass index, body weight, and scores on the Yale Brown Obsessive Compulsive Scale (modified for binge eating). One small study suggests that the opiate antagonist naltrexone may also reduce binge eating and block the urge to eat.
Patients with obesity and BED face multiple challenges. A therapeutic plan tailored to the individual patient’s needs is advisable. More information is available for the public at www.nationaleatingdisorders.org, the website for the National Eating Disorders Association.