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Evidence-Based Reviews

Binge eating disorder: Evidence-based treatments

Alone or combined, pharmacotherapy and CBT can reduce binging, psychopathology

Vol. 11, No. 05 / May 2012

Binge eating is consumption of an unusually large amount of food coupled with a feeling of loss of control over eating. Binge eating disorder (BED) is characterized by recurrent episodes of binge eating without inappropriate compensatory behaviors (eg, self-induced vomiting, misuse of laxatives, diuretics, or other agents, excessive exercise).1 It is the most common eating disorder in the United States, with a lifetime prevalence of approximately 3.5% in women and 2% in men.2 The diagnosis falls within the DSM-IV-TR category of eating disorders not otherwise specified,1 but clinicians often view it as a distinct clinical phenomenon. In DSM-IV-TR, an individual would meet criteria for BED if he or she engages in regular binge eating behavior in the absence of recurrent compensatory behaviors ≥2 days per week over 6 months.1 Proposed changes for DSM-5 recognize a distinct BED diagnosis, reduce the frequency criterion to once per week and the duration criterion to the past 3 months, and shift the focus from binge days to binge episodes (Table 1).3

Table 1

Proposed DSM-5 criteria for binge eating disorder

  1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
  2. The binge-eating episodes are associated with ≥3 of the following:
  3. Marked distress regarding binge eating is present
  4. The binge eating occurs, on average, at least once a week for 3 months
  5. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior (for example, purging) and does not occur exclusively during the course anorexia nervosa, bulimia nervosa, or avoidant/restrictive food intake disorder

Source:Reference 3

BED can occur in individuals of all body mass indices (BMI), but is common among individuals who are overweight or obese as well as those with depression or type 2 diabetes; BED can complicate treatment of these conditions.2,4,5 Primary treatment goals are:

  • abstinence from binge eating
  • improved psychological functioning
  • appropriate weight regulation in overweight patients.

We report on 3 approaches to BED treatment: medication only, behavioral intervention only, and medication plus behavioral intervention. This article provides insights about emerging changes in diagnostic criteria for BED as well as evidence-informed treatment options and recommendations.

The evidence base

We conducted a review of 23 BED studies: 7 medication only, 5 medication plus behavioral, and 11 behavioral only. We focused on studies conducted since September 2005 that included binge frequency, weight, and depression as primary outcomes (see Berkman et al6 for a review of BED treatment studies before 2005). The studies included 2,527 participants (2,216 women and 311 men). Although the sex distribution of BED in the general population tends to slightly favor women,2 the proportion of women presenting for treatment generally is considerably higher than that of men. In studies that reported on race and/or ethnicity, 1,639 participants were identified as white, 191 as African American, 25 as Hispanic, 2 as Asian, 1 as Native American, and 25 as “other.” Ages ranged from 18 to 77.

Several medications are effective

In placebo-controlled studies, a high-dose selective serotonin reuptake inhibitor (escitalopram7), 2 anticonvulsants (zonisamide8 and topiramate9), a selective norepinephrine reuptake inhibitor (atomoxetine10), and an appetite suppressant (sibutramine11) were associated with significant decreases in binge eating frequency, weight, and BMI in overweight/obese patients diagnosed with BED (Table 2). In an open-label trial, memantine—a N-methyl-D-aspartate receptor antagonist often used to treat symptoms of Alzheimer’s disease—was associated with a significant reduction in binge eating but no change in weight.12 Lamotrigine was not significantly different from placebo in reducing binge eating or weight, but showed promise in reducing metabolic parameters such as glucose and triglyceride levels commonly associated with obesity and type 2 diabetes.13 Because BED often is comorbid with obesity and type 2 diabetes, lamotrigine augmentation when treating obese individuals with BED warrants further investigation. As with any pharmacologic agent, carefully consider potential side effects and interactions with other drugs before prescribing medications for BED. Informing patients of potential side effects is crucial for patient safety and accuracy of the data collected in well-controlled treatment studies.

Table 2

Pharmacotherapy for binge eating disorder




Guerdjikova et al, 20087

Escitalopram, 10 to 30 mg/d, vs placebo for 12 weeks

Escitalopram was significantly better than placebo in reducing weight, BMI, and illness severity

McElroy et al, 20068

Zonisamide, 100 to 600 mg/d, vs placebo for 16 weeks

Zonisamide was significantly better than placebo in reducing BE, weight, BMI, and various aspects of unhealthy eating behavior

McElroy et al, 20079

Topiramate, 25 to 400 mg/d, vs placebo for 16 weeks

Topiramate was significantly better than placebo in reducing BE, weight, BMI, and related psychological features of BE

McElroy et al, 200710

Atomoxetine, 40 to 120 mg/d, vs placebo for 10 weeks

Atomoxetine was significantly better than placebo in reducing BE, weight, BMI, and obsessive-compulsive features of BE, and in achieving remission

Wilfley et al, 200811

Sibutramine, 15 mg/d, vs placebo for 24 weeks

Sibutramine was significantly better than placebo in reducing BE, weight, BMI, and related psychological features of BE

Brennan et al, 200812

Open-label memantine, 5 to 20 mg/d, for 12 weeks

Memantine was associated with decreased binge frequency and related psychological features of BE

Guerdjikova et al, 200913

Lamotrigine, 50 to 400 mg/d, vs placebo for 16 weeks

Lamotrigine was not significantly different from placebo

BE: binge eating; BMI: body mass index

CBT vs other behavioral approaches

Cognitive-behavioral therapy (CBT), which focuses on identifying and modifying unhealthy thoughts that maintain disordered eating behaviors, is the most widely studied behavioral intervention for BED. Other studied treatments include interpersonal psychotherapy (IPT), motivational interviewing (MI), and structured behavioral weight loss (BWL) (Table 3).14-24 IPT is a psychodynamically based, time-limited treatment that focuses on the interpersonal context of the disorder and on building interpersonal skills. MI emphasizes exploring and resolving ambivalence about treatment, and works to facilitate change through motivational processes. BWL is centered on making dietary and physical activity changes to achieve weight loss. Behavioral treatments have been delivered in various formats, such as an individual or group setting, by electronic interface, and via self-help approaches. Most studies compared active treatment to a control group, but some compared active treatments head-to-head.

Table 3

CBT and other behavioral interventions for BED




Annunziato et al, 200914

2 groups received CBT and hypocaloric diet for 8 weeks followed by 14 weeks of enhanced nutritional program (ie, reduced consumption of high energy density foods and once-daily liquid meal replacement) or control (normal diet)

Enhanced nutritional program was not significantly different from the control in reducing weight, BE, or psychological features of BE; variability in adherence to the enhanced nutritional program was identified as a significant effect modifier

Ashton et al, 200915

4 sessions of group CBT in an open trial

CBT was associated with significant reductions in BE and psychological features of BE in post-bariatric surgery patients

Dingemans et al, 200716

CBT vs wait-list control

CBT significantly better than the wait-list control in reducing BE and psychological features of BE, and in achieving abstinence from BE

Friederich et al, 200717

15-session CBT blended with elements of interpersonal therapy (IPT), nutritional counseling, and supervised walking program; no control group

Treatment significantly reduced weight, BE, and related psychological features of BE in patients meeting sub-threshold and full criteria for BED

Grilo et al, 200518

Guided self-help CBT (CBTgsh) vs guided self-help behavioral weight loss (BWLgsh) vs non-specific attention control for 12 weeks

CBTgsh significantly better than BWLgsh and control in BE remission; CBTgsh significantly better than BWLgsh, which was significantly better than control in reducing cognitive restraint; CBTgsh significantly better than control in reducing depression and eating-related psychopathology; no differences between groups in BMI change

Ricca et al, 201019

Individual (I-CBT) vs group CBT (G-CBT) for 24 weeks in patients meeting subthreshold and full criteria for BED

BE and BMI were significantly reduced in both groups at 24 weeks and 3-year follow-up. I-CBT was not better than G-CBT in reducing BE or weight at 24 weeks or 3-year follow-up; I-CBT was significantly better than G-CBT in reducing eating-related psychopathology at 24 weeks and 3-year follow-up; I-CBT was significantly better than G-CBT in recovery (ie, no longer meeting full BED criteria) at 24 weeks but not at 3-year follow-up

Schlup et al, 200920

8 weekly sessions of group CBT vs wait-list control

CBT was significantly better than wait-list control in reducing BE and eating concerns and in achieving abstinence at end of treatment; CBT was not different than control in reducing BMI; treatment-related reductions in BE and eating concerns were maintained at 12-month follow-up

Shapiro et al, 200721

10 weekly sessions of group CBT (G-CBT) vs CD-ROM delivered CBT (CD-CBT) vs wait-list control

G-CBT and CD-CBT were not different from each other but both were significantly better than wait-list control in reducing BE

Tasca et al, 200622

Group CBT (G-CBT) vs group psychodynamic interpersonal therapy (G-IPT) vs wait-list control for 16 weeks

G-CBT and G-IPT were not different from each other; G-CBT and G-IPT were significantly better than wait list in reducing BE and interpersonal problems (but not BMI) and increasing cognitive restraint post-treatment; depression was reduced in both groups at 6 months but only in G-IPT at 12 months; reductions in BE maintained at 12 months

Wilson et al, 201023

10 sessions of guided self-help CBT (CBTgsh) vs 19 sessions of IPT vs 20 sessions of behavioral weight loss (BWL) over 6 months

BWL was significantly better than IPT and CBTgsh in reducing BMI and in the number of patients achieving 5% weight loss at post-treatment but effects were not sustained over time; BWL was significantly better than CBTgsh in increasing dietary restraint

Cassin et al, 200824

Self-help book + motivational interviewing (SH-MI) vs self-help book alone (SH) for 16 weeks

SH-MI was significantly better than SH in reducing BE and depression

BE: binge eating; BED: binge eating disorder; BMI: body mass index; CBT: cognitive-behavioral therapy

Studies found that CBT and IPT are effective in reducing the frequency of binge eating, whether measured by the number of binge eating episodes or days a patient reports having engaged in binge eating.14-23 However, some studies suggested that CBT can help a substantial number of patients achieve abstinence from binge eating.16,20 Adding MI to a self-help approach may improve binge eating outcomes,24 and binge eating can be successfully reduced using individual, group, and CD-ROM delivery formats.21 In direct comparisons, individual CBT outperformed group CBT in helping patients recover from BED (ie, no longer meeting diagnostic criteria),19 and CBT delivered via guided self-help outperformed BWL in helping patients achieve remission.18

Psychological features of BED typically include low levels of cognitive restraint and high levels of disinhibition, hunger, and shape and weight concerns. Improvements in these psychological measures were observed with CBT,15-20,22 IPT,22 and MI.24 In direct comparisons, self-help CBT demonstrated greater reductions in perceived hunger and disinhibition than self-help BWL,18 and individual CBT outperformed group CBT in reducing shape and weight concerns.19 Isolated studies reported improvements in depression after self-help CBT18 and MI,24 and sustained improvements22 after group CBT (6 months) and group IPT (12 months). Additional research is needed to determine whether CBT crafted specifically for BED improves self-rated depression or if enhancements targeting depressive symptoms are required.

The impact of behavioral interventions on weight in overweight patients has been mixed. Although some CBT studies reported a substantial decrease in weight,17,19 others suggested that weight loss among patients treated with CBT is not superior to those in a wait-list control group16 or is not significant over the course of treatment.20,21 The impact of BWL on weight outcomes in BED also has been unimpressive: after 12 weeks, self-help BWL was no better than self-help CBT in reducing BMI18; after 16 weeks, BWL was better than CBT and IPT in achieving clinically significant (≥5%) weight loss, but this advantage was not sustained at 1- and 2-year follow-up.23 It is difficult to determine why successfully treated BED patients fail to lose weight because one would expect decreases in binge eating to lead to weight loss. It is possible that calories previously consumed during binge eating episodes are distributed over non-binge meals or that patients label binges and non-binge meals differently as a result of treatment.

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