Michael Posternak, MD.
At the time of writing, Dr. Posternak had no financial relationships with companies related to this material.
We regret that Dr. Posternak passed away after finishing this piece. He had a warm heart, a bright mind, and a keen eye for the needs of psychiatric patients.
Binge eating disorder (BED) was one of 15 new disorders introduced in DSM-5. Although we all have tendencies to overindulge on food, BED is distinguished by its frequency, lack of control, and negative consequences. Think of it as one side of the bulimia nervosa coin, ie, bingeing without the compensatory purging, fasting, or compulsive exercising that accompanies bulimia.
BED is more common than bulimia, with a prevalence rate of about 1% in the general population (Cossrow N et al, J Clin Psychiatry 2016;77(8):e968–e974) and 6%–7% in psychiatric outpatients (Taraldsen KW et al, Int J Eat Disord 1996;20(2):185–190). Although obesity and low self-esteem are common sequelae of binge eating, weight is irrelevant to the diagnosis—approximately 25% of BED patients have a normal BMI (Fairburn CG et al, Arch Gen Psychiatry 2000;57(7):659–665).
Principles of management
BED cannot be diagnosed in the presence of other eating disorders, but it is a frequent comorbidity of other psychiatric disorders, including depression, anxiety, OCD, ADHD, and substance use disorders. Patients rarely mention binge eating, however, and seldom present it as a chief complaint, so specific screening is usually necessary.
Despite being a secondary concern, there are several reasons to make BED a priority in treatment. Patients are typically highly motivated to address it, untreated BED can impede recovery from other disorders, and there are many effective treatment options to choose from.
Several types of psychotherapy are effective for BED, although no technique stands out as uniquely effective. Below are the principles I’ve found most useful:
Sometimes patients are successfully able to resist a binge, but this success comes at a cost. It can reinforce the notion that binge eating is a matter of willpower. When they are unable to resist the urge, this belief can set in motion a vicious cycle of dejection, low self-esteem, and resignation (Berkman ND et al. Management and Outcomes of Binge-Eating Disorder. Comparative Effectiveness Reviews, No. 160. Rockville, MD: Agency for Healthcare Research and Quality; December 2015).
To sidestep this cycle, I’ll typically say something like the following: “We all have our vulnerabilities, whether it be alcohol, gambling, or in your case, bingeing. Rather than wish it were otherwise, let’s acknowledge that this is your vulnerability, and let’s see if we can figure out a way to manage it better. But let’s start by thinking of binge eating as an unwanted habit rather than a defect in your character. Does that sound good to you?”
Each patient has their own pattern of bingeing. Some patients binge only on ice cream, while others eat anything in sight. Some patients eat out of boredom, while others eat when depressed. Virtually all patients binge alone—and often at night.
If ice cream is the problem, the moment to intervene is at the supermarket, not at midnight when the freezer is already stocked with Ben & Jerry’s. If food in general is the problem, a more comprehensive approach is required. Options include putting locks on the refrigerator or kitchen at night or being accountable to someone. For example, the patient can commit to calling or texting a friend each morning to tell them whether or not they were successful in abstaining the night before.
Engage in a collaborative discussion to develop a strategy your patient believes in. If they agree to refrain from purchasing ice cream, don’t stop there. Problem-solve further by asking, “What will you do when midnight comes and you have a strong urge to binge?”
Alcoholics Anonymous’ motto of “One day at a time” works for a reason. Most patients can easily imagine abstaining for a day but can’t imagine not drinking for the rest of their lives. As treatment starts, help your patient focus on getting through the next week. Once they do, each successive week should only get easier.
Patients will sometimes lack the control to stop eating, but almost always retain the ability to eat more.Eating in the late afternoon or early evening is a paradoxical intervention that serves two purposes: It prevents patients from feeling starved in the evening when they are at highest risk, and it reframes caloric restriction as the problem, not the solution. Some research suggests that high-protein snacks may be more effective at reducing subsequent binges than high-carbohydrate ones (Latner JD and Wilson GT, Int J Eat Disord 2004;36(4):402–415).
Many medications may be helpful for BED, but patients are often ambivalent about taking them because they see the problem as a weakness that they should be able to overcome. A useful compromise is to agree on a set time period for them to try changing with behavioral strategies before considering a medication trial. For some, the desire to avoid medication might be a useful motivator in itself. Another option is to introduce medication as a short-term trial. If a patient achieves sustained abstinence over one to three months, you can agree to try to taper off the medication.
Despite its relative novelty as a formal disorder, the pathophysiology of BED is fairly well elucidated. fMRI studies of BED show enhanced reward sensitivity in the orbitofrontal cortex and anterior cingulate cortex in response to images of food along with hypoactivation in the brain areas involved in self-regulation and impulse control. Increases in serotonin and noradrenergic neurotransmission have been implicated in reducing impulsivity in the frontal cortex, while dysregulation in dopamine and opioid transmission in the mesolimbic pathways is believed to affect reward processing (Heal DJ and Smith SL, J Psychopharmacol 2022;36(6):680–703).
The pathophysiology of BED is distinct from that of bulimia and obesity, but obesity does influence treatment response in one important way. Most BED patients who are overweight are only able to achieve sustained remission from the eating disorder if they have success with weight loss as well (McElroy SL et al, JAMA Psychiatry 2015;72(3):235–246).
Medication options for BED
Synthesizing the literature for BED is a complex task because randomized controlled trials (RCTs) often lump BED with other eating disorders that have distinct pathophysiologies and treatments, frequently include only obese patients whose treatments may differ from those with a lower BMI, and are unable to account for the diverse comorbidities that BED often presents with. With these caveats in mind—and the note that comorbidities should affect your medication selection—below I rank the various medication options that have been studied based on their proven efficacy, their cost, and my clinical experience:
Combining medications with psychotherapy
When compared head to head, psychotherapy and medication bring about similar reductions in binge eating, and their combination works better than either alone. In a comparison of naltrexone/bupropion alone or in combination with behavioral therapy, remission rates were highest for the combination (57%) compared to 37% for medication alone, 31% for behavioral therapy alone, and 18% for placebo (Grilo et al, 2022).
BED is common among psychiatric outpatients and should always be included in your initial diagnostic evaluation. BED accompanies many other psychiatric disorders. Therefore, even if it’s not the chief complaint, discuss the rationale for possibly making binge eating the first order of business you decide to tackle. Using some simple behavioral techniques along with either lisdexamfetamine (Vyvanse) or a variety of second-line options, you can expect to achieve sustained improvement, if not remission, in a relatively short amount of time.
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