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:

1. Reframe binge eating as a problem of strategy rather than of ­willpower.

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?”

2. Identify your patient’s pattern of binge eating.

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?” 

3. Think short term.

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. 

4. Suggest eating more in the late afternoon or early evening.

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).

5. Stress that medications can help.

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.

Pathophysiology

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:

1. Lisdexamfetamine (Vyvanse). Lisdexamfetamine is the only medication that is FDA approved for BED. Animal studies have already shown that it suppresses binge eating in rats (including on chocolate!) and that weight loss is sustained over time. Its benefits are believed to be mediated by its dopaminergic and noradrenergic effects, and may relate to its appetite-suppressant ability to control impulsivity in populations like ADHD. The optimal dosage range for adults is 50–70 mg (McElroy SL et al, Neuropsychopharmacology 2016;4(5):2051–2060). Methylphenidate, in contrast to lisdexamfetamine, does not suppress appetite as much as amphetamines and lacks placebo-controlled trials in BED. 
2. Naltrexone. As an opioid blocker, ­naltrexone has potential value in blocking reward sensations. One early pilot study suggested that high doses (ie, 200–300 mg) may be effective for treating binge eating and more effective than standard doses (ie, 50–100 mg), and this corresponds with my clinical experience (Jonas JM and Gold MS, Psychiatry Res 1988;24(2):194–195). Although this study has never been replicated and some experts are skeptical of the benefits of opioid blocking for BED, naltrexone’s immediate benefits, favorable side effect profile, and long track record with addictive behaviors make it an attractive second-line option. 
3. Naltrexone SR (32 mg/day) + bupropion SR (360 mg/day) (Contrave). This combination is FDA approved for obesity. One recent RCT (Grilo CM et al, Am J Psychiatry 2022;179(12):927–937) and one long-term, open-label study (Guerdjikova AI et al, Adv Ther 2017;34(10):2307–2315) suggest that naltrexone/bupropion may help with binge eating frequency and weight loss. The combination likely takes advantage of the appetite-suppressing effects of bupropion and the reward-inhibiting effects of naltrexone. To save on cost, the two can be prescribed separately as generics (naltrexone 50 mg QAM along with bupropion XL 150–300 mg QAM).
4. SSRIs and SNRIs. Fluoxetine is FDA approved in bulimia at a target dose of 60 mg QD, and small controlled trials support its use in BED as well at a similar target dose. It is also the SSRI with the lowest risk of weight gain. Sertraline has similar evidence at a range of 100–200 mg QD. Among the SNRIs, only duloxetine has controlled-trial evidence, and in that study the patients also had active depression (60–120 mg/day). 
5. Topiramate. This anticonvulsant is well studied in both bulimia and BED. In BED, it has the backing of large randomized controlled trials at a daily dose of 200–600 mg, but also the risk of renal stones and cognitive impairment (McElroy SL et al, Biol Psychiatry 2007;61(9):1039–1048). Its cognitive risks are reduced by starting low (25 mg QD) and raising slowly (by 25 mg every week). 

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).

CARLAT VERDICT