Christine M. Peat, PhD

Orthorexia nervosa, from the Greek orthos (straight, proper) and orexia (appetite), is a disorder in which a person demonstrates a pathological obsession not with weight loss but with a “pure” or healthy diet, which can contribute to significant dietary restriction and food-related obsessions. Although the disorder is not a formal diagnosis in DSM 5,¹ it is increasingly reported on college campuses and in medical practices, and has been the focus of media attention.

How common is orthorexia?
The precise prevalence of orthorexia nervosa is unknown; some authors have reported estimates as high as 21% of the general population² and 43.6% of medical students.³ The higher prevalence among medical students might be attributable to the increased focus on factors that can contribute to illnesses (eg, food and diet), and thus underscores the importance of screening for orthorexia symptoms among this population.

How do you identify the disorder?
Orthorexia nervosa was first described by Bratman,⁴ who observed that a subset of his eating disorder patients were overly obsessed with maintaining an extreme “healthy diet.” Although diagnostic criteria for orthorexia nervosa have not been established, Bratman proposed the following as symptoms indicative of the disorder:

• spending >3 hours a day thinking about a healthy diet
• worrying more about the perceived nutritional quality or “purity” of one’s food than the pleasure of eating it
• feeling guilty about straying from dietary beliefs
• having eating habits that isolate the affected person from others.

Given the focus on this disorder in the media and its presence in medical practice, it is important that you become familiar with the symptoms associated with orthorexia nervosa so you can provide necessary treatment. A patient’s answers to the following questions will aid the savvy clinician in identifying symptoms that suggest orthorexia nervosa⁵:

• Do you turn to healthy food as a primary source of happiness and meaning, even more so than spirituality? 
• Does your diet make you feel superior to other people?
• Does your diet interfere with your personal relationships (family, friends), or with your work? 
• Do you use pure foods as a “sword and shield” to ward off anxiety, not just about health problems but about everything that makes you feel insecure?
• Do foods help you feel in control more than really makes sense?
• Do you have to carry your diet to further and further extremes to provide the same “kick”?
• If you stray even minimally from your chosen diet, do you feel a compulsive need to cleanse?
• Has your interest in healthy food expanded past reasonable boundaries to become a kind of brain parasite, so to speak, controlling your life rather than furthering your goals?

No single item is indicative of orthorexia nervosa; however, this list represents a potential clinical picture of how the disorder presents.

Overlap with anorexia nervosa. Although overlap in symptom presentation between these 2 disorders can be significant (eg, diet rigidity can lead to malnutrition, even death), each has important distinguishing features. A low weight status or significant weight loss, or both, is a hallmark characteristic of anorexia nervosa; however, weight loss is not the primary goal in orthorexia nervosa (although extreme dietary restriction in orthorexia could contribute to weight loss). Additionally, a person with anorexia nervosa tends to be preoccupied with weight or shape; a person with orthorexia nervosa is obsessed with food quality and purity. Finally, people with orthorexia have an obsessive preoccupation with health, whereas those with anorexia are more consumed with a fear of fat or weight gain.

Multimodal treatment is indicated
Treating orthorexia typically includes a combination of interventions common to other eating disorders. These include cognitive-behavioral therapy, dietary and nutritional counseling, and medical management of any physical sequelae that result from extreme dietary restriction and malnutrition. Refer patients in whom you suspect orthorexia nervosa to a trained therapist and a dietician who have expertise in managing eating disorders.

It is encouraging to note that, with careful diagnosis and appropriate treatment, recovery from orthorexia is possible,⁶ and patients can achieve an improved quality of life.

Orthorexia nervosa, from the Greek orthos (straight, proper) and orexia (appetite), is a disorder in which a person demonstrates a pathological obsession not with weight loss but with a “pure” or healthy diet, which can contribute to significant dietary restriction and food-related obsessions. Although the disorder is not a formal diagnosis in DSM 5,¹ it is increasingly reported on college campuses and in medical practices, and has been the focus of media attention.

How common is orthorexia?
The precise prevalence of orthorexia nervosa is unknown; some authors have reported estimates as high as 21% of the general population² and 43.6% of medical students.³ The higher prevalence among medical students might be attributable to the increased focus on factors that can contribute to illnesses (eg, food and diet), and thus underscores the importance of screening for orthorexia symptoms among this population.

How do you identify the disorder?
Orthorexia nervosa was first described by Bratman,⁴ who observed that a subset of his eating disorder patients were overly obsessed with maintaining an extreme “healthy diet.” Although diagnostic criteria for orthorexia nervosa have not been established, Bratman proposed the following as symptoms indicative of the disorder:

• spending >3 hours a day thinking about a healthy diet
• worrying more about the perceived nutritional quality or “purity” of one’s food than the pleasure of eating it
• feeling guilty about straying from dietary beliefs
• having eating habits that isolate the affected person from others.

Given the focus on this disorder in the media and its presence in medical practice, it is important that you become familiar with the symptoms associated with orthorexia nervosa so you can provide necessary treatment. A patient’s answers to the following questions will aid the savvy clinician in identifying symptoms that suggest orthorexia nervosa⁵:

• Do you turn to healthy food as a primary source of happiness and meaning, even more so than spirituality? 
• Does your diet make you feel superior to other people?
• Does your diet interfere with your personal relationships (family, friends), or with your work? 
• Do you use pure foods as a “sword and shield” to ward off anxiety, not just about health problems but about everything that makes you feel insecure?
• Do foods help you feel in control more than really makes sense?
• Do you have to carry your diet to further and further extremes to provide the same “kick”?
• If you stray even minimally from your chosen diet, do you feel a compulsive need to cleanse?
• Has your interest in healthy food expanded past reasonable boundaries to become a kind of brain parasite, so to speak, controlling your life rather than furthering your goals?

No single item is indicative of orthorexia nervosa; however, this list represents a potential clinical picture of how the disorder presents.

Overlap with anorexia nervosa. Although overlap in symptom presentation between these 2 disorders can be significant (eg, diet rigidity can lead to malnutrition, even death), each has important distinguishing features. A low weight status or significant weight loss, or both, is a hallmark characteristic of anorexia nervosa; however, weight loss is not the primary goal in orthorexia nervosa (although extreme dietary restriction in orthorexia could contribute to weight loss). Additionally, a person with anorexia nervosa tends to be preoccupied with weight or shape; a person with orthorexia nervosa is obsessed with food quality and purity. Finally, people with orthorexia have an obsessive preoccupation with health, whereas those with anorexia are more consumed with a fear of fat or weight gain.

Multimodal treatment is indicated
Treating orthorexia typically includes a combination of interventions common to other eating disorders. These include cognitive-behavioral therapy, dietary and nutritional counseling, and medical management of any physical sequelae that result from extreme dietary restriction and malnutrition. Refer patients in whom you suspect orthorexia nervosa to a trained therapist and a dietician who have expertise in managing eating disorders.

It is encouraging to note that, with careful diagnosis and appropriate treatment, recovery from orthorexia is possible,⁶ and patients can achieve an improved quality of life.

Orthorexia nervosa, from the Greek orthos (straight, proper) and orexia (appetite), is a disorder in which a person demonstrates a pathological obsession not with weight loss but with a “pure” or healthy diet, which can contribute to significant dietary restriction and food-related obsessions. Although the disorder is not a formal diagnosis in DSM 5,¹ it is increasingly reported on college campuses and in medical practices, and has been the focus of media attention.

How common is orthorexia?
The precise prevalence of orthorexia nervosa is unknown; some authors have reported estimates as high as 21% of the general population² and 43.6% of medical students.³ The higher prevalence among medical students might be attributable to the increased focus on factors that can contribute to illnesses (eg, food and diet), and thus underscores the importance of screening for orthorexia symptoms among this population.

How do you identify the disorder?
Orthorexia nervosa was first described by Bratman,⁴ who observed that a subset of his eating disorder patients were overly obsessed with maintaining an extreme “healthy diet.” Although diagnostic criteria for orthorexia nervosa have not been established, Bratman proposed the following as symptoms indicative of the disorder:

• spending >3 hours a day thinking about a healthy diet
• worrying more about the perceived nutritional quality or “purity” of one’s food than the pleasure of eating it
• feeling guilty about straying from dietary beliefs
• having eating habits that isolate the affected person from others.

Given the focus on this disorder in the media and its presence in medical practice, it is important that you become familiar with the symptoms associated with orthorexia nervosa so you can provide necessary treatment. A patient’s answers to the following questions will aid the savvy clinician in identifying symptoms that suggest orthorexia nervosa⁵:

• Do you turn to healthy food as a primary source of happiness and meaning, even more so than spirituality? 
• Does your diet make you feel superior to other people?
• Does your diet interfere with your personal relationships (family, friends), or with your work? 
• Do you use pure foods as a “sword and shield” to ward off anxiety, not just about health problems but about everything that makes you feel insecure?
• Do foods help you feel in control more than really makes sense?
• Do you have to carry your diet to further and further extremes to provide the same “kick”?
• If you stray even minimally from your chosen diet, do you feel a compulsive need to cleanse?
• Has your interest in healthy food expanded past reasonable boundaries to become a kind of brain parasite, so to speak, controlling your life rather than furthering your goals?

No single item is indicative of orthorexia nervosa; however, this list represents a potential clinical picture of how the disorder presents.

Overlap with anorexia nervosa. Although overlap in symptom presentation between these 2 disorders can be significant (eg, diet rigidity can lead to malnutrition, even death), each has important distinguishing features. A low weight status or significant weight loss, or both, is a hallmark characteristic of anorexia nervosa; however, weight loss is not the primary goal in orthorexia nervosa (although extreme dietary restriction in orthorexia could contribute to weight loss). Additionally, a person with anorexia nervosa tends to be preoccupied with weight or shape; a person with orthorexia nervosa is obsessed with food quality and purity. Finally, people with orthorexia have an obsessive preoccupation with health, whereas those with anorexia are more consumed with a fear of fat or weight gain.

Multimodal treatment is indicated
Treating orthorexia typically includes a combination of interventions common to other eating disorders. These include cognitive-behavioral therapy, dietary and nutritional counseling, and medical management of any physical sequelae that result from extreme dietary restriction and malnutrition. Refer patients in whom you suspect orthorexia nervosa to a trained therapist and a dietician who have expertise in managing eating disorders.

It is encouraging to note that, with careful diagnosis and appropriate treatment, recovery from orthorexia is possible,⁶ and patients can achieve an improved quality of life.

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

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

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

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.

Combining treatments

BED patients often are treated with a combination of psychotherapy and pharmacotherapy (Table 4).^25-29 When added to CBT, topiramate was associated with improvements in weight and some psychological outcomes,^25,26 but fluoxetine was not.^27,28 Direct comparisons also showed that CBT, alone or combined with fluoxetine, was better than fluoxetine alone in reducing binge eating.²⁷ When combined with an individualized hypocaloric diet, the anti-obesity medication orlistat reduced weight in obese BED patients but had no appreciable effect on binge eating.²⁹ Collectively, the studies we reviewed suggested that combining medication and CBT may improve binge eating and weight loss outcomes; however, additional trials are necessary to determine more definitively which medications combined with CBT are best at producing sustained weight loss while reducing binge eating frequency.

Table 4

Combining medication with behavioral interventions for BED

Recommendations

Evidence suggests that pharmacotherapy and CBT—alone or in combination—are effective in reducing binge eating, and pharmacotherapy is effective in reducing weight in overweight individuals with BED. More research is needed for IPT and MI. It is unclear which medications provide the greatest benefit in terms of binge eating remission; however, pharmacotherapy has a clear advantage in facilitating short-term weight loss. Also, all BED patients should receive medical management to address possible complications such as hypertension or type 2 diabetes. In addition to reducing binge eating, CBT can improve related psychological comorbidities (eg, eating-related psychopathology and depression) and may have additional benefit when combined with pharmacotherapy.

In light of these findings, we recommend augmenting psychotherapeutic care with pharmacotherapy and medical management to address all relevant psychological and medical domains. Future investigations should address the benefits of coordinated psychological and medical care and evaluate how to maintain treatment gains.

Related Resources

• Binge Eating Disorder Association. www.bedaonline.com.
• Brownley KA, Berkman ND, Sedway JA, et al. Binge eating disorder treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007;40(4):337-348.

Drug Brand Names

• Atomoxetine • Strattera
• Escitalopram • Lexapro
• Fluoxetine • Prozac
• Lamotrigine • Lamictal
• Memantine • Namenda
• Orlistat • Alli, Xenical
• Sertraline • Zoloft
• Sibutramine • Meridia
• Topiramate • Topamax, Topiragen
• Zonisamide • Zonegram

Disclosures

Dr. Peat receives a post-doctoral trainee grant from the National Institutes of Health.

Drs. Brownley, Berkman, and Bulik report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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

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

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

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.

Combining treatments

BED patients often are treated with a combination of psychotherapy and pharmacotherapy (Table 4).^25-29 When added to CBT, topiramate was associated with improvements in weight and some psychological outcomes,^25,26 but fluoxetine was not.^27,28 Direct comparisons also showed that CBT, alone or combined with fluoxetine, was better than fluoxetine alone in reducing binge eating.²⁷ When combined with an individualized hypocaloric diet, the anti-obesity medication orlistat reduced weight in obese BED patients but had no appreciable effect on binge eating.²⁹ Collectively, the studies we reviewed suggested that combining medication and CBT may improve binge eating and weight loss outcomes; however, additional trials are necessary to determine more definitively which medications combined with CBT are best at producing sustained weight loss while reducing binge eating frequency.

Table 4

Combining medication with behavioral interventions for BED

Recommendations

Evidence suggests that pharmacotherapy and CBT—alone or in combination—are effective in reducing binge eating, and pharmacotherapy is effective in reducing weight in overweight individuals with BED. More research is needed for IPT and MI. It is unclear which medications provide the greatest benefit in terms of binge eating remission; however, pharmacotherapy has a clear advantage in facilitating short-term weight loss. Also, all BED patients should receive medical management to address possible complications such as hypertension or type 2 diabetes. In addition to reducing binge eating, CBT can improve related psychological comorbidities (eg, eating-related psychopathology and depression) and may have additional benefit when combined with pharmacotherapy.

In light of these findings, we recommend augmenting psychotherapeutic care with pharmacotherapy and medical management to address all relevant psychological and medical domains. Future investigations should address the benefits of coordinated psychological and medical care and evaluate how to maintain treatment gains.

Related Resources

• Binge Eating Disorder Association. www.bedaonline.com.
• Brownley KA, Berkman ND, Sedway JA, et al. Binge eating disorder treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007;40(4):337-348.

Drug Brand Names

• Atomoxetine • Strattera
• Escitalopram • Lexapro
• Fluoxetine • Prozac
• Lamotrigine • Lamictal
• Memantine • Namenda
• Orlistat • Alli, Xenical
• Sertraline • Zoloft
• Sibutramine • Meridia
• Topiramate • Topamax, Topiragen
• Zonisamide • Zonegram

Disclosures

Dr. Peat receives a post-doctoral trainee grant from the National Institutes of Health.

Drs. Brownley, Berkman, and Bulik report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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

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

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

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.

Combining treatments

BED patients often are treated with a combination of psychotherapy and pharmacotherapy (Table 4).^25-29 When added to CBT, topiramate was associated with improvements in weight and some psychological outcomes,^25,26 but fluoxetine was not.^27,28 Direct comparisons also showed that CBT, alone or combined with fluoxetine, was better than fluoxetine alone in reducing binge eating.²⁷ When combined with an individualized hypocaloric diet, the anti-obesity medication orlistat reduced weight in obese BED patients but had no appreciable effect on binge eating.²⁹ Collectively, the studies we reviewed suggested that combining medication and CBT may improve binge eating and weight loss outcomes; however, additional trials are necessary to determine more definitively which medications combined with CBT are best at producing sustained weight loss while reducing binge eating frequency.

Table 4

Combining medication with behavioral interventions for BED

Recommendations

Evidence suggests that pharmacotherapy and CBT—alone or in combination—are effective in reducing binge eating, and pharmacotherapy is effective in reducing weight in overweight individuals with BED. More research is needed for IPT and MI. It is unclear which medications provide the greatest benefit in terms of binge eating remission; however, pharmacotherapy has a clear advantage in facilitating short-term weight loss. Also, all BED patients should receive medical management to address possible complications such as hypertension or type 2 diabetes. In addition to reducing binge eating, CBT can improve related psychological comorbidities (eg, eating-related psychopathology and depression) and may have additional benefit when combined with pharmacotherapy.

In light of these findings, we recommend augmenting psychotherapeutic care with pharmacotherapy and medical management to address all relevant psychological and medical domains. Future investigations should address the benefits of coordinated psychological and medical care and evaluate how to maintain treatment gains.

Related Resources

• Binge Eating Disorder Association. www.bedaonline.com.
• Brownley KA, Berkman ND, Sedway JA, et al. Binge eating disorder treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007;40(4):337-348.

Drug Brand Names

• Atomoxetine • Strattera
• Escitalopram • Lexapro
• Fluoxetine • Prozac
• Lamotrigine • Lamictal
• Memantine • Namenda
• Orlistat • Alli, Xenical
• Sertraline • Zoloft
• Sibutramine • Meridia
• Topiramate • Topamax, Topiragen
• Zonisamide • Zonegram

Disclosures

Dr. Peat receives a post-doctoral trainee grant from the National Institutes of Health.

Drs. Brownley, Berkman, and Bulik report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.