Approach Considerations
Treatment for binge eating disorder (BED) is generally performed on an outpatient basis. However, if the patient has severe comorbidities such as self-harm, suicidality, or substance misuse or the severity of the binge eating places the person at risk for significant physical illness, residential treatment should be considered. [29, 37] The role of loneliness should not be underestimated, especially when treatment is ineffective. [38]
Consultations
Consultation/counseling from a nutrition specialist can be very effective in binge eating disorder (BED), especially when provided in combination with cognitive-behavioral therapy (CBT) or other interventions. [39]
Consultation with a psychologist and/or psychiatrist may also be considered.
Medication Treatment
Medication treatment should not be the first or only treatment for bingeeating disorder because of the efficacy of some nonpharmacologic approaches.
Fluoxetine (Prozac) is the only medication thus far approved by the US Food and Drug Administration for acute and maintenance treatment of binge eating and vomiting behaviors in patients with moderate-to-severe bulimia nervosa. However, other medications such as sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), and escitalopram (Lexapro), as well as other selective serotonin/norepinephrine reuptake inhibitors (SNRIs) and antidepressants that are generally FDA approved for depression and obsessive compulsive disorder, can also be useful alternatives when fluoxetine is not tolerated or is ineffective. Nonetheless, antidepressants are associated with weight gain in some cases, which can be a significant barrier to success. [40]
Lisdexamfetamine (Vyvanse) was approved by the FDA in January 2015 to treat moderate-to-severe BED in adults. It is the first FDA-approved medication to treat this condition. [41, 42]
Antiepileptic medications that decrease obsessive and compulsive behavior, such as topiramate, zonisamide, and lamotrigine, as well as other medications that decrease compulsive eating, such as exenatide and liraglutide, may be effective owing to their effect on the regulation of neuropeptide Y that may help to control weight. Antiobesity medications such as phentermine and orlistat are also options for controlling weight.
Older antiobesity medications such as sibutramine and d-fenfluramine have been removed from the worldwide market owing to cardiovascular safety concerns.
Acamprosate appeared to have a favorable side effect profile but may not be consistently effective for BED. Memantine also appeared ineffective. Some other medications that appear to be ineffective or that worsen BED include valproate, phenytoin, and oxcarbazepine. [43]
So far, pilot studies of agomelatine, a medication that increases levels of melatonin, have shown that it may be especially useful in persons that also have night eating syndrome (NES), which is characterized by reduced feeding during the day, evening hyperphagia accompanied by difficulty falling asleep (initial insomnia), and difficulties in sleep maintenance, including frequent nocturnal awakenings that are associated with episodes (while awake) of craving and compulsive ingestion of food and that can be associated with obesity. [39, 44]
Forty-five stable adults (ie, non-rapid cycling, absence of clinically significant hypomanic symptoms) with bipolar I/II disorder and comorbid attention deficit hyperactivity disorder (ADHD) were enrolled in a phase IV, 4-week, flexible-dose, open-label study of adjunctive LDX. All subjects were initiated at 30 mg/day of adjunctive LDX for the first week with flexible dosing (ie, 30-70 mg/day) between weeks 2 and 4. Of 45 subjects enrolled, 40 received adjunctive LDX (mean dose, 60 ± 10 mg/day).
A statistically significant decrease from baseline to endpoint was evident in weight (P < 0.001), BMI (P < 0.001), fasting total cholesterol (P = 0.011), low-density lipoprotein cholesterol (P = 0.044), and high-density lipoprotein cholesterol (P = 0.015), but not triglycerides or blood glucose. Significant reductions were also observed in leptin (P = 0.047), but not in ghrelin, adiponectin, or resistin levels. [45]
Behavior Modification and Other Alternatives to Medication Treatment
Cognitive behavior therapy (CBT) is a treatment of choice in binge eating disorder (BED), especially in the context of high levels of specific eating disorder psychopathology, such as overvaluation of body shape and weight. A randomized placebo-controlled trial found that CBT with placebo was superior to fluoxetine only, and adding fluoxetine to CBT did not enhance findings compared to adding placebo to CBT at 12-month follow-up after treatment completion. [46]
A meta-analysis of 45 studies found only moderate support for the efficacy of CBT and CBT guided self-help, and modest support for interpersonal psychotherapy (IPT), selective serotonin reuptake inhibitors (SSRI), and lisdexamfetamine in the treatment of adults with BED in terms of cessation of or reduction in the frequency of binge eating. [47]
Family therapy should be considered when family dynamics figure prominently as triggers for binging and in children and younger adolescents. Family therapy can be very helpful, but has not been proven superior to other approaches for BED such as interpersonal psychotherapy (IPT) or dialectical behavior therapy (DBT).
Family therapy can be effective to improve communication by decreasing negative emotional expressivity. Improved positive communication between family and friends of the person with BED may play an important role in encouraging persistence with treatment. [30]
IPT is a proven treatment for BED and focuses on identification of interpersonal conflict as triggers for binges. [48]
Guided self-help (GSH) appears to be less effective than CBT or DBT for BET. Although this approach is popular because of its low cost and easy accessibility (eg, as with self-help groups such as Something Fishy), this approach should be viewed carefully, as not all online GSH resources are balanced and supportive. [49, 19]
Integrative response therapy, which has the mnemonic RESPONSES (Reflect, Exercise, Start distracting, Problem Solve, Open communication, get distaNce, Soothe, get cEntered, Social and/or pleasurable activities) appeared to be an effective group-based cognitive restructuring and emotion management technique. Integrative response therapy appeared to show significant reduction in numbers of binge days by providing a structured intervention that provides temporary relief from aversive emotions. [50]
Behavioral weight loss (BWI):Self-monitoring strategies for behavioral weight loss typically include the following (1) A paper diary of diet, physical activity, weight, and obesity-related risk behaviors such as drinking sugary drinks to self-monitor weight maintenance and/or (2) electronic devices such as web-based dietary monitoring, mobile applications with food diaries, and activity trackers can be used with the potential to allow for more proximal reporting and immediate feedback. [18]
Dialectical behavior therapy (DBT) can be helpful to reduce binge eating, as it helps to reduce sudden intense surges of emotion. DBT is a manual-based treatment developed by Dr. Marsha Linehan that helps the person identify interpersonal relationship situations that can trigger cognitions that cause dysphoric emotions, to use their own strengths in collaboration with the therapist to be able to self–soothe, and to accept dysphoric emotions without needing to engage in maladaptive behaviors. [51, 52]
Embodied cognition therapy includes the idea that abnormal eating behaviors are both influenced by and influence how the brain encodes incoming perceptual data about the body such as the person’s perception of their own body image and internal states such as hunger and satiety. [53]
Virtual reality therapy uses technology to help to identify triggers for binge eating and is especially helpful in persons who do not integrate body image with a solid sense of self by reducing shame and improving body image. The idea of autobiographical awareness and memory as an external observation can be integrated in virtual reality. [54]
Mindfulness meditation is a Western form of meditation derived from a very old Buddhist practice called Vipassana or insight meditation, the skill of paying attention to one’s experiences with calm patient acceptance and compassion in a nonjudgmental manner. Mindfulness meditation can be practiced alone or with others; it involves the practice of being fully present in the moment with the breath to help with centering. Mindfulness meditation, when added to other interventions, appeared to be helpful. [55]
Yoga has appeared to provide lasting maintenance of stable BMI in some persons with BED. [56]
Bariatric surgery, although proven to help obese individuals with weight loss, may not be as effective in persons with BED unless they also receive an evidence-based intervention to ensure that the weight loss from the bariatric surgery is maintained. [57]
Long-Term Monitoring
Functional consequences of binge eating disorder (BED) include social role adjustment problems, impaired health-related quality of life and life satisfaction, increased medical morbidity and mortality, and increased associated health care utilization compared with persons with equivalent BMI who do not have BED.
Being overweight or obese is often associated with BED.
Psychiatric comorbidities such as bipolar disorder, anxiety, and depressive disorders, as well as borderline personality disorder, can potentially confer increased risk of suicide or self-harm; long-term monitoring is important to ensure safety and positive outcomes.
Lower self-esteem has been associated with increased risk of suicidality, especially for males who are candidates for bariatric surgery. [58]
