Binge eating disorder (BED) is characterized by recurrent episodes of binge eating not accompanied by inappropriate compensatory behaviors. Although it is not yet officially recognized, it was included in the current Diagnostic and Statistical Manual of Mental Disorders (DSM) as a disorder to be studied, with research criteria included. It is also slated to be included in the next DSM as one of the officially recognized eating disorders.
There have been several treatment modalities employed in its treatment: pharmacotherapy, psychotherapy, and a combination of the two. Being a “young” disorder, BED still needs future research to show which modality treats it best in the long run. Approaches to Treatment of Binge Eating Disorder What Is BED? How Is It Different From Bulimia Nervosa? Binge eating disorder (BED) is characterized by recurrent episodes of binge eating not accompanied by inappropriate compensatory behaviors (Sadock & Sadock, 2003).
Although binge eating, by itself, is more commonly associated with bulimia nervosa, binge eating disorder is recognized as a separate entity. Unlike BED, bulimia nervosa involves excessive concern with body shape and weight, and bulimics often have a “self-perception of being too fat, with an intrusive dread of fatness” (World Health Organization [WHO], 1993).
Moreover, the absence of compensatory behaviors further distinguishes BED from the non-purging type of bulimia nervosa, which is defined by the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, as when the individual “has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas” (American Psychiatric Association [APA], 2000). Diagnosis of Binge Eating Disorder
Although binge eating disorder still has to gain official recognition, the Text Revision of DSM-IV (APA, 2000) lays down the following “research criteria” for diagnosing the disorder: A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) eating, in a discrete period of time (e. g. , within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances (2) the sense of lack of control over eating during the episode (e. g. , a feeling that one
cannot stop eating or control what or how much one is eating) B. Binge-eating episodes are associated with three (or more) of the following: (1) eating much more rapidly than normal (2) eating until feeling uncomfortably full (3) eating large amounts of food when not feeling physically hungry (4) eating alone because of being embarrassed by how much one is eating (5) feeling disgusted with oneself, depressed, or very guilty after overeating C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least 2 days a week for 6 months. E.
The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e. g. , purging, fasting, excessive exercise, etc. ) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa. Several issues have been raised regarding the criteria mentioned above. For example, one question raised by some experts in the field is that there is no definite way to assess just how much food constitutes “an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
” Fulfilling these criteria would at best be a subjective process. While the DSM-IV criteria for BED is usually applied to adults, Marcus and Kalarchian (2003) have proposed a separate set of provisional research criteria for diagnosing BED in children. These are: A. Recurrent episodes of being eating. An episode of binge eating is characterized by both of the following: (1) food seeking in absence of hunger (e. g. after a full meal) (2) a sense of lack of control over eating (e. g.
, endorse that ‘‘When I start to eat, I just can’t stop’’) B. Binge episodes are associated with one or more of the following: (1) food seeking in response to negative affect (e. g. , sadness, boredom, restlessness) (2) food seeking as a reward (3) sneaking or hiding food C. Symptoms persist over a period of 3 months. D. Eating is not associated with the regular use of inappropriate compensatory behaviors (e. g. , purging, fasting, excessive exercise) and does not occur exclusively during the course of
anorexia nervosa or bulimia nervosa. Some of the questionnaires used to diagnose binge eating disorder are: the Binge Eating Scale (BES), the Three Factor Eating Questionnaire, the Body Shape Questionnaire, the Structured Clinical Interview for the Diagnosis of DSM Disorders (SCID), and the Eating Disorders Examination (EDE). The Treatment of Binge Eating Disorder Overview In the management of BED, the primary goal is to achieve abstinence from binge eating (Bulik, Brownley & Shapiro, 2007).
However, studies have shown that BED has comorbid conditions that require as much attention, such as depression, generalized anxiety disorder, panic attacks and even attempts at suicide (Grucza, Przybeck & Cloninger, 2007). Furthermore, since patients diagnosed with BED do not usually engage in inappropriate compensatory behaviors, they are usually obese as well, a condition that sometimes causes more concern in professionals caring for BED patients because of its health implications. Because of the different aspects of this disorder, different treatment modalities are being used, with some experts favoring one and others favoring another.
Pharmacotherapy Medications used to treat binge eating disorder include appetite suppressants, anticonvulsants, selective serotonin and norepinephrine reuptake inhibitors, and tricyclic antidepressants. These have been studied in double-blind placebo-controlled trials, and the results, though modest, have been promising (Appolinario & McElroy, 2004). Appetite suppressants. According to Appolinario, Bacaltchuk, Sichieri, Claudino, Godoy-Matos, Morgan, Zanella & Coutinho (2003), fenfluramine hydrochloride was the first antiobesity agent shown to be effective in treating binge eating disorder.
However, this drug has been withdrawn from the market because of intolerable side effects. Currently, the anti-obesity agent that seems to be the most studied in the treatment of BED is sibutramine. Sibutramine is a drug that inhibits the reuptake of serotonin, norepinephrine, and, to some extent, dopamine. A study by Appolinario et al. (2003) showed that patients taking sibutramine, as opposed to those given a placebo pill, experienced a significant reduction in the number of days with binge episodes. Whereas those in the placebo group actually gained some weight, the patients given sibutramine lost an average of 7.
4 kg. The study participants were asked to fill out the Binge Eating Scale and the Beck Depression Inventory before and after their treatment program, and the sibutramine group had significantly lower scores after treatment. The study cites dry mouth and constipation as the adverse reactions commonly encountered by those taking sibutramine. The authors concluded that sibutramine is effective and well tolerated for treating obese BED patients. Another study supporting the use of sibutramine in BED was published in the American Journal of Psychiatry in January 2008.
Wilfley, Crow, Hudson, Mitchell, Berkowitz, Blakesley, Walsh, and the Sibutramine Binge Eating Disorder Research Group (2008) found that patients taking sibutramine (15 mg daily for 24 weeks) were able to significantly reduce the following measures: weekly binge frequency, weight (mean of 4. 3 kg), frequency of binge days, body mass index, and eating pathology, such as cognitive restraint, disinhibition and hunger. Moreover, these patients also experienced global improvement and had a greater percentage of abstinence from binge eating (58. 7%, compared with the 42. 8% of the placebo group). Anticonvulsants.
In the February 2003 edition of the American Journal of Psychiatry, McElroy, Arnold, Shapira, Keck, Rosenthal, Karim, Kamin & Hudson (2003) reported that 30 patients with binge eating disorder randomly assigned to receive a flexible dose (25 to 600 mg per day) of the anticonvulsant drug topiramate had a significantly greater rate of reduction in binge frequency, binge day frequency, weight (mean loss of 5. 9 kg), and body mass index. They also had lower scores on the Yale-Brown Obsessive Compulsive Scale, which was modified for binge eating, and on the Clinical Global Impression severity scale.
However, six patients receiving topiramate were unable to continue participating in the study because of adverse events, mostly headaches and paresthesias. The researchers concluded that topiramate was useful for the short-term treatment of BED. The journal Biological Psychiatry also published a study by McElroy, Hudson, Capece, Beyers, Fisher, Rosenthal, and the Topiramate Binge Eating Disorder Research Group (2007), which showed that 195 patients taking topiramate were able to reduce binge eating days per week, binge episodes per week, weight (mean loss of 4.
5 kg), and body mass index compared with those assigned to take placebo. Thirty percent of those taking topiramate left the study, mostly due to adverse effects such as paresthesia, upper respiratory tract infection, somnolence and nausea. However, thirty percent of those taking the placebo pill also were not able to continue with the program. Despite the adverse events reported, the authors concluded that topiramate is well tolerated and was efficacious in treating BED and its features, particularly obesity.
Another antiepileptic drug that was evaluated for efficacy in the treatment of binge eating disorder is zonisamide. McElroy, Kotwal, Guerdjikova, Welge, Nelson, Lake, D’Alessio, Keck & Hudson (2006) reported in the Journal of Clinical Psychiatry that thirty patients given zonisamide (100 to 600 mg per day for 16 weeks) had a reduction in the frequency of their binge eating episodes, body weight, body mass index, and scores on the Yale-Brown Obsessive Compulsive Scale Modified for Binge Eating and the Clinical Global Impressions Severity Scale.
Eight of the patients receiving zonisamide discontinued treatment because of accidental injury with bone fracture, psychological complaints and cognitive complaints. In conclusion, the researchers noted that zonisamide was efficacious in treatment of BED with obesity but that it was not well tolerated. Selective serotonin reuptake inhibitors (SSRIs) and norepinephrine reuptake inhibitors. Several selective serotonin reuptake inhibitors have been shown to have beneficial effects in the management of binge eating disorder.
Among the earliest SSRI’s shown to be useful in BED treatment was fluvoxamine. Hudson, McElroy, Raymond, Crow, Keck, Carter, Mitchell, Strakowski, Pope, Coleman & Jonas (1998) reported that forty-two patients who received a flexible dose of fluvoxamine (50 to 300 mg) for 9 weeks had a significantly greater decrease in the frequency of binges and in body mass index. Furthermore, these patients given fluvoxamine achieved a greater reduction in Clinical Global Impression severity score and a greater rate of increase in Clinical Global Impression improvement scores.
However, fluvoxamine did not have a significant effect on the participants’ Hamilton depression scale scores, and the proportion of patients who dropped out of the study because of adverse effects came from the fluvoxamine group. Furthermore, another study done 5 years later on a different, smaller set of patients showed that there was a reduction in binge frequency, eating concern, shape concern and weight concern in both the group receiving fluvoxamine and the group receiving placebo (Pearlstein, Spurell, Hohlstein, Gurney, Read, Fuchs & Keller, 2003).
The authors say this is just an example of the “inconsistent results of antidepressant studies in binge eating disorder” (Pearlstein et al. , 2003). Another SSRI shows greater promise. McElroy, Hudson, Malhotra, Welge, Nelson & Keck (2003) conducted a 6-week, double-blind, flexible-dose (20 to 60 mg per day) study on the efficacy of citalopram in reducing the frequency of binge eating episodes.
They reported that the 19 patients receiving citalopram, compared with those receiving placebo, had a significantly greater rate of reduction in the frequency of binge eating episodes, frequency of binge days, weight, body mass index and severity of illness. In addition, citalopram was said to be well tolerated by the participants of the study. A head-to-head comparison of two SSRI’s – sertraline and fluoxetine – was conducted by Leombruni, Piero, Lavagnino, Brustolin, Campisi & Fassino (2008) and published in the journal Progress in Neuro-psychopharmacology and Biological Psychiatry.
Twenty-two participants were given 100 to 200 mg of sertraline daily, while twenty were given 40 to 80 mg of fluoxetine per day. After 8 weeks, participants from both groups had significant weight loss and their scores in the Binge Eating Scale improved. There was no significant difference found between the two drugs, and the researchers concluded that both SSRI’s are effective options in treating patients with BED. A drug that inhibits both serotonin and norepinephrine reuptake was studied by Noma, Uwatoko, Yamamoto & Hayashi (2008).
Although the trial did not focus exclusively on individuals with binge eating disorder but consisted of 25 binge eaters, some of whom were diagnosed with anorexia or bulimia nervosa. These patients received the drug milnacipran for 8 weeks and were found to have improved scores in relation to their drive for binge eating and regret for the same. Milnacipran was noted to be more effective in patients without purging. Venlafaxine, another medication that inhibits the reuptake of both serotonin and norepinephrine, was mentioned by Appolinario et al.
(2003) as effective in BED therapy. McElroy, Guerdjikova, Kotwal, Welge, Nelson, Lake, Keck & Hudson (2007) examined the effects of atomoxetine, a norepinephrine reuptake inhibitor, on BED. Twenty patients who received the drug had a significant decrease in binge-eating episode frequency, binge day frequency, weight, and body mass index. Their scores on the Clinical Global Impressions Severity of Illness scale, the Yale-Brown Obsessive Compulsive Scale Modified for Binge Eating obsession subscale, and the Three Factor Eating Questionnaire hunger subscale improved as well.
However, three of the patients receiving atomoxetine asked to discontinue their treatment because of increased depressive symptoms, constipation or nervousness. Tricyclic antidepressants. Bulik, Brownley & Shapiro (2007), in a review of the diagnosis and management of binge eating disorder, also mentions imipramine as one of the drugs that were shown in trials to be effective in the treatment of BED. Imipramine is a tricyclic antidepressant that is used mainly for the treatment of depression and enuresis. A drug from the same family, desipramine, was also mentioned as having beneficial effects in BED.
There have indeed been many drugs explored by research for the treatment of binge eating disorder. However, while a lot of studies show that they do have a beneficial effect on patients with BED, particularly with regards to a reduction in binge frequency and weight, the results are somewhat modest. In addition, there have been no long-term studies tracking the efficacy of these drugs as yet. And then, of course, there is the concern that many of those individuals taking these drugs might give them up due to the adverse effects they cause.
More importantly, the drugs do not address the underlying cause of binge eating, the psychopathology in individuals that lead them to take in large amounts of food despite the knowledge that doing so could harm them physically and socially. Thus, while many experts in the field would agree that medications help to curb the comorbidities of BED, they still encourage the use of psychotherapy. Psychotherapy Cognitive behavioral therapy. The behavioral therapeutic approach to binge eating disorder that is probably the most tested is cognitive behavioral therapy, or CBT (Bulik, Brownley & Shapiro, 2007).
As the name implies, the theory behind this practice is the cognitive behavioral model of binge eating, which “postulates that binge eating develops in response to restrictive food intake and occurs in the context of ongoing dietary restraint and the experience of negative emotions” (Levine & Marcus, 2003). In short, inaccurate thoughts and beliefs – for example, those about body shape and weight – lead to inappropriate eating behavior. CBT helps patients identify these binge-triggering thoughts and modify them so as to accomplish binge abstinence.
According to Bulik, Brownley & Shapiro (2007), cognitive behavioral therapy has been reported by several studies to be effective in reducing “binge frequency, related psychological aspects of binge eating (restraint, disinhibition, and hunger), depressed mood, and ratings of illness severity in individuals with BED. ” Levine & Marcus (2003) note that, while cognitive behavioral therapy has been traditionally used in the management of individuals with bulimia nervosa, the technique has been modified to accommodate the differences between bulimia nervosa and binge eating disorder.
For example, unlike people with bulimia nervosa, those with binge eating disorder tend to be obese, so CBT can directly target cognitions about having a large body size. They explain, “Overweight individuals with BED may be helped to accept their body size and to restructure maladaptive thoughts about the amount of weight loss they are likely to achieve. That is, although modest weight loss may relate to improvements in binge eating, for most BED patients this decrease may not correspond with their desired weight loss. It is therefore important that cognitions about acceptable body sizes be targeted during treatment.
” Interpersonal psychotherapy. Another type of therapy that has found success in patients with bulimia nervosa and has since been also applied to people with binge eating disorder is interpersonal psychotherapy, or IPT. While CBT focuses on the thoughts that trigger eating binges, interpersonal psychotherapy operates on the theory that binge eating stems from the internal milieu created by specific social and interpersonal problems. Thus, it “focuses on identifying and addressing specific, problematic interpersonal patterns, in an effort to ameliorate dysfunctional eating behaviors” (Levine & Marcus, 2003).
As with CBT, IPT is focused, structured and time-limited. However, it does not address the patient’s beliefs about eating, weight and shape and, unlike CBT, does not directly target eating behaviors. In the Archives of General Psychiatry, Wilfley, Welch, Stein, Spurrell, Cohen, Saelens, Dounchis, Frank, Wiseman & Matt (2002) report on a comparative study that they conducted between CBT and IPT. Both were done in a group setting, and the participants in each group went through 20 weekly sessions of therapy. Results showed that “binge-eating recovery rates” were similar for both CBT and IPT immediately after treatment.
They further conducted follow-up on each participant and noted that, while, there was a slight increase in binge eating when the treatment ended, the frequency of such binges remained significantly lower than the frequency prior to initiation of either CBT or IPT. In addition, the researchers reported significant reductions in psychiatric symptoms, and these were maintained through follow-up. They noted that, while dietary restraint decreased more quickly in patients who underwent CBT, a similar level of dietary restraint was accomplished by those who underwent IPT by the time of follow-up.
The participants’ weight decreased only slightly, but significantly, and the authors then concluded that group IPT is a reasonable alternative to group CBT for dealing with overweight BED patients. Dialectical behavior therapy. Another type of therapy used for the treatment of BED is dialectical behavior therapy, or DBT. This is described by Levine & Marcus (2003) as “a comprehensive treatment program based on cognitive and behavioral principles and complemented by the use of acceptance-based strategies derived primarily from Zen Buddhism.
” Patients undergo a weekly individual outpatient therapy and, at the same time, a weekly group skills therapy that has the goal of increasing behavioral skills that can help them deal with binge eating. According to Bulik, Brownley & Shapiro (2007), dialectical behavior therapy “fosters the development of skills in the domains of mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. ” Although it is still considered an “alternative” form of behavior therapy, there have been studies showing that DBT has led to a greater reduction in binge days, binge episodes, and concerns with weight, shape and eating.
Other behavioral therapies. Aside from cognitive behavior therapy, interpersonal psychotherapy and dialectical behavior therapy, Bulik, Brownley & Shapiro (2007) mention self-help, exercise and virtual reality therapy as treatment modalities that have been tried in patients with BED. Self-help interventions are delivered in various formats, and may be done with or without structure, and with out without the aid of a facilitator or a therapist.
It has been shown by some studies to result in greater reductions in the mean number of binge days and in the clinical severity of BED. Abstinence and cessation rates were also reported to be improved with self-help, but weight loss was not significantly achieved. Medications and Psychotherapy: Combined and Compared Several studies have explored the option of combining pharmacotherapy with psychotherapy. Bulik, Brownley & Shapiro (2007) discuss the results of these studies. For example, a trial compared fluoxetine alone with CBT alone and fluoxetine plus CBT.
The authors of that trial reported that CBT plus fluoxetine, and CBT alone, were more effective than fluoxetine alone in reducing the frequency of binges, concerns with eating and body shape, disinhibition and depression. Another comparison discussed in the same paper compared desipramine alone, weight loss therapy, and CBT. Bulik, Brownley & Shapiro (2007) relate: “Binge eating was significantly reduced after 12 weeks in both groups receiving CBT; however, this effect did not persist at 36 weeks of treatment. Average weight loss was greatest in the weight loss therapy group in the early stages of treatment, but over time (i. e.
, at 3-month follow-up) the group receiving desipramine lost the most weight. Desipramine showed no clear advantage in reducing symptoms of depression. ” Claudino, de Oliveira, Appolinario, Cordas, Duchesne, Sichieri & Bacaltchuk (2007) compared topiramate alone with CBT plus topiramate and concluded that “topiramate added to CBT improved the efficacy of the later, increasing binge remission and weight loss in the short run. Topiramate was well tolerated, as shown by few adverse events during treatment. ” Finally, Molinari, Baruffi, Croci, Marchi & Petroni (2005) conducted a comparison of CBT alone, fluoxetine alone, and CBT plus fluoxetine.
Results showed that “the two groups which underwent psychotherapy resulted in a better outcome – in terms of number of bingeing episodes, maintenance of weight loss reduction from baseline and psychological well being – than the group treated with pharmacological therapy alone. ” The authors concluded that the results of their study highlight the importance of a multidisciplinary approach to binge eating disorder. However, as with pharmacotherapy alone and with psychotherapy alone, the long-term efficacy of a combined drugs-and-talk approach to binge eating disorder still has to be proven by future studies.
Practical Advice To Tell Patients Empowering patients to take control of their disorder is also important. Smith, Barston, Segal & Segal (2008) offer the following tips that concerned eating disorder professionals can give their patients: • Eat breakfast. Skipping breakfast often leads to overeating later in the day, so start your day right with a healthy meal. Eating breakfast also jump starts your metabolism in the morning. Studies show that people who eat breakfast are thinner than those who don’t. • Avoid temptation. You’re much more likely to overeat if you have junk food, desserts, and unhealthy snacks in the house.
Remove the temptation by clearing your fridge and cupboards of your favorite binge foods. • Stop dieting. The deprivation and hunger of strict dieting can trigger food cravings and the urge to overeat. Instead of dieting, focus on eating in moderation. Find nutritious foods that you enjoy and avoid labeling foods as “good” or “bad. ” • Exercise. Not only will exercise help you lost weight in a healthy way, but it also lifts depression, improves overall health, and reduces stress. The natural mood-boosting effects of exercise can help put a stop to emotional eating. • Destress.
Learn how to cope with stress in healthy ways that don’t involve food. Conclusion Binge eating disorder is still relatively “young. ” With its anticipated inclusion in the next edition of the DSM, a lot of studies have turned their attention to this eating disorder that has only been recognized as an entity separate from the other eating disorder in the last decade. Hopefully, these studies, and the ones still to be conducted, will provide a sound basis for how best to approach binge eating disorder. More importantly, only future research can tell which treatment modalities really work best in the long term.
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