Binge eating disorder

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Binge eating disorder is an eating disorder characterized by recurrent uncontrollable binge eating episodes that occur at least once a week for 3 months. Binge eating episodes are associated with significant distress, without compensatory behaviors to counteract weight gain. Causes are multifactorial and similar to those of anorexia nervosa (e.g., genetic factors, psychiatric disorders, and psychosocial factors such as bullying). It is important to assess for malnutrition severity in affected individuals, regardless of body weight or body mass index (BMI). The diagnosis is confirmed if individuals fulfill all of the DSM-5 diagnostic criteria for binge eating disorder. Individuals should be evaluated for associated complications (e.g., comprehensive assessment of patients who are overweight or obese) and underlying conditions that may affect weight or cause a change in eating behaviors (e.g., thyroid disorder). Treatment is typically provided in an outpatient setting, but the presence of red flags in eating disorders may indicate the need for hospitalization. All individuals should be referred for psychotherapy (preferably cognitive behavioral therapy) and nutritional management, including binge eating prevention strategies. Pharmacotherapy (e.g., with antidepressants or lisdexamfetamine) may be considered to help reduce the frequency of binge eating episodes.

• Prevalence: most common eating disorder in adults in the US (∼ 2–5% of general population)
• Peak age of onset: adolescents and young adults; can also begin in adulthood
• Sex: ♀ > ♂

Epidemiological data refers to the US, unless otherwise specified.

The etiology of binge eating disorder is multifactorial and not entirely understood. Contributory factors are similar to those associated with anorexia nervosa; see “Etiology of Anorexia nervosa” for details. ^[4]

• Genetic factors (family history is common)
• Strict dieting and having access to preferred binge foods
• Psychological issues (e.g., poor body self-image, stress, childhood bullying)

• Recurrent binge eating episodes that are not associated with inappropriate weight compensatory behaviors : See also “DSM-5 diagnostic criteria for binge eating disorder.”
• Pronounced obesity at a young age is common; BMI may also be normal.
• Can be associated with:
  • ASCVD risk factors: i.e., hyperlipidemia, metabolic syndrome, type 2 diabetes, cardiovascular disease
  • Psychological conditions: e.g., major depression disorder, alcohol use disorder, suicidal ideation
• Course: typically chronic, relapsing disease

Approximately 25% of affected individuals experience suicidal ideation. ^[2]

General principles

• See “Screening for eating disorders” for indications and screening modalities. ^[5][6][7]
• Determine if individuals fulfill all of the DSM-5 diagnostic criteria for binge eating disorder to confirm the diagnosis. ^[2]
• Evaluate for complications and comorbidities, and rule out possible organic etiologies for change in weight and/or eating behaviors: See “Initial evaluation for a suspected eating disorder.”

DSM-5 diagnostic criteria ^[2][8]

All individuals with binge eating disorder experience emotional distress about their binge eating, but not all individuals necessarily experience distress over their weight or appearance. ^[2][6]

Individuals with binge eating disorder often conceal their eating behaviors (e.g., by eating alone). ^[2]

Severity (according to the DSM-5) ^[2]

Based on the number of binge eating episodes per week

• Mild: 1–3 episodes/week
• Moderate: 4–7 episodes/week
• Severe: 8–13 episodes/week
• Extreme: ≥ 14 episodes/week

• Bulimia nervosa ^[2]
• Mood disorders (i.e., major depressive disorder, bipolar disorder)
• Impulsive behavior of borderline personality disorder
• Other conditions associated with unexpected weight gain, e.g.: ^[8]
  • Cushing disease
  • Hypothyroidism
  • Prader-Willi syndrome
• Substance use disorder (i.e., alcohol and/or cannabis use) ^[8]

The differential diagnoses listed here are not exhaustive.

General principles ^[6][7][8]

• Determine the most appropriate care setting: See “Disposition for eating disorders.”
• Establish treatment goals, e.g., ^[7]
  • Decrease the number of binge eating episodes
  • Improve disordered thoughts and beliefs about weight, body image, and eating behaviors
  • Improve knowledge of healthy eating habits, including binge eating prevention strategies.
• Comanage nutritional management with a dietitian.
• Refer all individuals for psychotherapy (e.g., cognitive behavioral therapy).
• Pharmacotherapy may help reduce the frequency of binge eating episodes (e.g., by reducing the impulse to binge); options include:
  • Antidepressants (e.g., SSRIs)
  • Lisdexamfetamine (topiramate may be considered as an alternative): may also help with weight reduction
• Consider additional management for patients who are overweight or obese as needed.
• Identify and manage associated comorbidities; see “Clinical features.”
• Regularly reassess for remission. ^[2]
  • Partial remission : binge eating episodes occur < 1 time per week (on average) for a sustained period of time
  • Full remission : none of the criteria for binge eating disorder are met for a sustained period of time

Nutritional management ^[7]

• Evaluate nutritional intake.
• Assess for food insecurity.
• Provide education on healthy eating habits, including binge eating prevention strategies.

Psychotherapy ^[7][8]

First-line therapy for binge eating disorder

• Preferred modalities
  • Cognitive behavioral therapy (in-person; individual or group format) ^[6][7][9]
  • Interpersonal therapy
• Alternatives
  • Web-based CBT or CBT-based guided self-help programs ^[7][9]
  • Dialectical behavioral therapy ^[8]

Pharmacotherapy ^[6][7][8]

Research on pharmacotherapy for binge eating disorder has primarily involved adults, therefore, there are no clear recommendations for adolescents. ^[6][7]

• Indications
  • Individuals who prefer medication rather than psychotherapy
  • Adjunctive therapy to psychotherapy for patients with:
    • Moderate or severe binge eating disorder
    • Lack of response to psychotherapy alone
• Preferred agents
  • Antidepressants (e.g., SSRIs) ^[7][9]
  • Lisdexamfetamine ^[7][9]
    • Lisdexamfetamine is a stimulant and therefore carries a risk of misuse
    • Use with caution in patients with hypertension and/or cardiac disease. ^[7]
• Alternative agent: Topiramate may be considered if the benefits outweigh the risks. ^[7]
  • Potential adverse effects: cognitive effects, paresthesias, and teratogenicity.
  • Topiramate is teratogenic; women of childbearing age must use effective contraception during treatment.

The antidepressant bupropion lowers the seizure threshold and is contraindicated in individuals with a history of anorexia nervosa, bulimia nervosa, or purging behaviors, and those with seizure disorders. ^[7]

Weight reduction is a possible side effect of the binge eating disorder medications lisdexamfetamine and topiramate, although neither are specifically approved for weight loss. ^[6][7]

Management of patients with overweight or obesity ^[8]

• Pharmacotherapy for weight loss or bariatric surgery may be considered if appropriate.
• Identify and treat underlying conditions contributing to weight gain (e.g., PCOS) and/or complications of obesity.

Recommend binge eating prevention strategies instead of dietary restrictions (e.g., avoiding specific food groups, limiting calories), as restrictions can inadvertently increase binge eating. ^[7]

• Obesity
• Metabolic syndrome
• See also “Complications of eating disorders.”

We list the most important complications. The selection is not exhaustive.