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Binge-eating disorder
Binge-Eating Disorder: Prevalence, Predictors,
and Management in the Primary Care Setting
Karen K. Saules, PhD, Jillian Carey, MS, Meagan M. Carr, MS, and Rachel M. Sienko, MS
ABSTRACT
• Objective: To describe the epidemiology, clinical features, clinical course, medical complications, and
treatment of binge-eating disorder (BED). • Methods: Review of the literature.
• Results: BED, the most common eating disorder, is
a distinct pattern of binge eating accompanied by
a sense of loss of control over eating without inappropriate compensatory behaviors. Because people
with BED more commonly seek treatment for the
psychological and medical factors that are associated
with the disorder, patients’ first point of contact with
the medical profession is likely to be the primary care
physician (PCP). The PCP’s role includes making
efforts to screen for BED symptoms, employing motivational interviewing strategies to enhance likelihood
of following through with treatment, providing psychoeducational information about eating and weight control, monitoring eating, weight, and related medical
problems at follow-up visits, and making referrals to
behavioral health specialists who can deliver empirically supported treatments for BED. • Conclusion: Proper screening and referral in the
primary care setting can optimize the likelihood that patients obtain empirically supported treatment.
B
inge-eating disorder (BED), first described by
Stunkard in the 1950s, is a distinct pattern of
binge eating, accompanied by a sense of loss of
control over eating without inappropriate compensatory behaviors [1]. It was not until the publication of
DSM-IV-TR [2] that BED received systematic study as
a separate diagnostic category, when it was included in
the appendix Criteria Sets and Axes Provided for Further Study. Until recently, individuals reporting binge
eating without recurrent compensatory behavior were
diagnosed with an eating disorder not otherwise specified. More recently, the American Psychiatric Association
512 JCOM November 2015 Vol. 22, No. 11
approved BED for inclusion in DSM-5 as its own category of eating disorder [3]. The diagnostic criteria for
BED are delineated in Table 1. In contrast to BED, bulimia nervosa is a longstanding diagnostic category that
refers to recurrent episodes of binge eating, accompanied
by a sense of loss of control over eating and recurrent
inappropriate compensatory behaviors to prevent weight
gain (eg, self-induced vomiting, misuse of laxatives or
diuretics, fasting)
BED is the most common eating disorder, but it
is one for which many do not seek treatment directly.
Rather, those struggling with BED more commonly
seek treatment for the psychological and medical factors
that are strongly associated with the disorder. As will be
reviewed below, these factors include poor social adjustment, functional impairment, psychological distress and
psychiatric comorbidity, and myriad medical sequelae
due to obesity and weight cycling. As such, the BED
patient’s point of first contact with the medical profession is most likely to be with the primary care physician,
who has several roles in the treatment of BED. There is
a limited evidence base for pharmacological treatment of
BED, with some medications yielding short-term reductions in binge eating, but none with strong support for
long-term efficacy [4]. However, with the recent FDA approval of lisdexamfetamine dimesylate for the treatment
of moderate to severe BED, this picture may change.
Nonetheless, pharmacologic interventions for comorbid
medical conditions will fall solidly in the bailiwick of
the primary care physician. In addition, the primary
care physician’s role includes making efforts to screen for
BED symptoms; employing motivational interviewing
strategies to enhance likelihood of following through
with treatment; providing psychoeducational information about eating and weight control; monitoring eating,
From the Department of Psychology, Eastern Michigan University, Ypsilanti, MI.
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Case-based review
weight, and related medical problems at follow-up visits;
and making referrals to behavioral health specialists who
can deliver empirically supported treatments for BED.
Finally, because BED is typically associated with weight
gain over time [5], the primary care physician is encouraged to reinforce the clinical significance of weight maintenance as opposed to necessarily promoting a goal of
weight loss. The rationale for this primary care approach
is reviewed below, in consideration of the scientific literature and a case study highlighting common clinical
features.
CASE STUDY
Initial Presentation
A 35-year-old Caucasian woman schedules an
appointment for her annual physical examination with her primary care physician. She reports generally good health but complains of low mood, joint pain,
and difficulties managing her weight. Her blood pressure is managed with 100 mg/day of metoprolol. The
only other medication she takes is birth control (ethinyl
estradiol 20 mcg).
Physical Examination
During physical examination, it is determined that the
patient is 5'6" and weighs 286 lb, with a body mass index
(BMI) of 46.2 kg/m2, placing her in WHO obesity class
III. The patient’s blood pressure is 130/85 mm Hg
(medically managed), and her heart rate is 83 bpm. The
patient states that she has been experiencing episodes of
low mood off and on most of her life; she recently ended
a relationship, which has exacerbated her symptoms. The
physician states that the patient has gained a significant
amount of weight since her last physical examination.
The patient reports that she quit smoking 6 months ago
and has since gained approximately 30 lb; she has considered smoking again to manage her weight.
Table 1. DSM-5 Diagnostic Criteria for Binge-Eating
Disorder (307.51; F50.8)
A. Recurrent episodes of binge eating. An episode of binge
eating is characterized by both of the following:
1. Eating, in a discrete period of time (for example, within
any 2-hour period), an amount of food that is definitely
larger than what most people would eat in a similar period of time under similar circumstances
2. A sense of lack of control over eating during the episode
(eg, a feeling that one cannot stop eating or control what
or how much one is eating)
B. The binge-eating episodes are associated with 3 (or more)
of the following:
1. Eating much more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically
hungry
4. Eating alone because of feeling embarrassed by how
much one is eating
5. Feeling disgusted with oneself, depressed, or very guilty
afterwards
C. Marked distress regarding binge eating is present
D. The binge eating occurs, on average, at least once a week
for 3 months
E. The binge eating is not associated with the recurrent use of
inappropriate compensatory behavior as in bulimia nervosa
(for example, purging) and does not occur exclusively during
the course of bulimia nervosa or anorexia nervosa
Specify if:
In partial remission: After full criteria for binge-eating disorder were previously met, binge eating occurs at an average
frequency of less than 1 episode per week for a sustained
period of time
In full remission: After full criteria for binge-eating disorder
were previously met, none of the criteria have been met
for a sustained period of time
Specify current severity:
The minimum level of severity is based on the frequency of
episodes of binge eating (see below). The level of severity
may be increased to reflect other symptoms and the degree
of functional disability.
Mild: 1-3 binge-eating episodes per week.
Moderate: 4-7 binge-eating episodes per week.
• What are the diagnostic criteria for BED?
Severe: 8-13 binge-eating episodes per week.
Extreme: 14 or more binge-eating episodes per week.
Adapted from reference 3.
BED diagnostic criteria (Table 1) have been closely
examined for their validity and clinical utility, and several have been the subject of intense debate in the BED
literature. The first BED criterion, recurrent episodes of
binge eating, refers to 3 essential components: amount of
food, time period, and a subjective experience of loss of
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control. The majority of debate regarding this criterion
revolves around the requirement for consumption of a
“large amount of food.” There are 2 primary arguments
against this criterion. First, it is inherently subjective and
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requires the person making the diagnosis to distinguish
between normative food intake and excessive food intake
[6]. There is also some debate as to whether or not individuals with BED actually consume large amounts of
food when they binge. However, research supports that
those with BED may consume over 1000 kcal during
binge episodes, far more than those without BED who
are asked to binge eat in the lab [7,8].
Nonetheless, a distinction has been made between
objective binge-eating episodes (OBE) and subjective
binge eating episodes (SBE) [9]. OBEs are binge eating episodes that meet the full criteria including a large
amount of food and a subjective loss of control. SBEs, in
contrast, are binge eating episodes that include a subjective loss of control but not a large quantity of food. If
consumption of a large quantity of food is essential to
the underlying pathology of BED, one would expect that
OBEs and SBEs would be associated with different clinical characteristics. However, several studies have failed to
find significant difference between individuals reporting
OBEs and SBEs with regard to age, age of BE onset, BE
severity, interpersonal problems, depressive symptoms,
generalized psychopathology, and ED-related psychopathology [10–13]. Results regarding prognosis are mixed,
with some suggesting that SBE more readily responds
to placebo, while others suggest that SBEs are slower to
remit than OBEs [11,13,14]. With respect to primary
care, this literature suggests that it is not necessary for
busy primary care physicians to devote time to understanding the amount of food consumed by the patient;
if the patient perceives that her eating is out of control
and excessive, that can generally be considered valid
data in terms of considering a BED diagnosis, particularly when combined with even moderately overweight
status.
In contrast to the controversy regarding amount of
food, the majority of studies suggest that BED binge
eating episodes fall within the 2-hour duration specified
by the DSM-5 criteria, although longer durations have
been reported [13]. The loss of control (LOC) criterion
also appears to be relatively well-supported across studies
[13,14]. LOC is a key defining feature of a binge eating
episode for individuals with and without BED [15–18].
Furthermore, the emotional distress associated with loss
of control has been associated with depressive symptoms,
appearance dissatisfaction, and poorer mental healthrelated quality of life [19]. In contrast, one study found
that 18.6% of self-reported binges were not associated
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with loss of control [20]. Of note, there is some concern
that the focus on LOC in the diagnostic criteria may lead
to under diagnosis of BED among men, as women with
BED were more likely than men to identify LOC as a
core aspect of a binge eating episode [17].
The second DSM-5 criterion for BED requires that
BE episodes be associated with 3 or more of the following: (a) eating more rapidly than normal; (b) eating until
uncomfortably full; (c) eating large amounts of food in
the absence of hunger; (d) eating alone because of embarrassment about how much one is eating; and (e) feeling
disgusted with oneself, depressed, or very guilty after
overeating. This criterion is not as controversial as the
first, and has correspondingly not received as much attention in the BED literature. However, results from a handful of studies provide some support for their inclusion,
particularly in light of the fact that individuals are only
required to endorse 3 of the 5 symptoms [13–15,17,21].
The third criteria for BED requires that individuals
experience “marked distress” about BE. Only one known
study has directly evaluated the distress criterion, and its
validity was confirmed by results that suggested individuals with full-threshold BED had significantly greater
ED-related psychopathology and depressive symptoms
as compared to individuals who met all but the distress
criteria for a BED diagnosis [22].
The fourth criteria for BED stipulates that BE occurs an average of once a week for 3 months. Previously,
DSM-IV-TR required more frequent episodes, at least
2 days a week for 6 months, but this was criticized as
lacking in empirical basis [23]. The current state of the
evidence suggests that, with regard to frequency of BE
episodes, BED best fits a continuous model rather than
a categorical model. That is, symptoms and related impairment exist across a severity spectrum as a function of
how often BE episodes occur. For example, in a critical
review, Wilson and Sysko noted that individuals with
sub-threshold frequency of BE episodes had less severe
psychopathology than those meeting criteria for DSMIV BE frequency (ie, at least 2 days a week for 6 months),
but they were still significantly more impaired than those
who did not binge eat [24]. The authors asserted that
there was no empirical rationale for preserving the criteria of 2 binge days per week for 6 months, and indeed,
DSM-5 adopted a more relaxed standard. As is the case
with symptoms of many psychological disorders, there
does not appear to be a definitive and concrete point at
which binge eating becomes pathological [23]. Fortuwww.jcomjournal.com
Case-based review
nately, reliability for the new criteria is good and appears
superior to the DSM-IV criteria [25].
Finally, the last criteria for BED—which remains
unchanged from the provisional criteria in DSM-IV-TR
—is essentially a rule-out that states that BE should not
be accompanied by the regular use of “inappropriate
compensatory behaviors” or exclusively occur during the
course of anorexia or bulimia. These criteria have also
been criticized as being subjective, particularly in light of
the fact that individuals with BED often report a history
of infrequent purging behavior and frequently engage in
weight-loss attempts [6,13,14]. However, the need for
a rule-out is clear given that BE also occurs during the
course of bulimia and anorexia, binge-eating/purging
type, and it is supported by the low rates of crossover
from BED to bulimia and/or anorexia [26].
Remission and severity specifiers are new to DSM-5.
With respect to the latter, a recent study observed small
but significant elevations in eating pathology among
those with moderate severity BED, relative to the eating
pathology experienced by those with mild severity, but
there were no differences in level of associated depression.
Interestingly, a better differentiator of severity of eating
pathology and depression among patients with BED was
overvaluation of shape/weight [27]. As such, the primary
care physician might be better advised to focus on indicators of this important variable by querying the extent
to which the patient’s shape and weight have influenced
how she feels about (judges/thinks/evaluates) herself as a
person, rather than using the number of BED symptoms
alone as the indicator of severity.
• What is the epidemiology of BED?
Based on DSM-IV-TR criteria, the overall lifetime prevalence rate for BED has been reported to be 2.8%, and it
is more common in women (3.5%) than men (2%) [28];
the overall 12-month prevalence rate is 1.2% (1.6% in
women and 0.8% in men) [28]. Using DSM-5 criteria,
a recent study observed that lifetime prevalence of BED
by age 20 was 3.0% for BED and an additional 3.6% for
subthreshold BED, with peak age of onset (for both)
between ages 18 to 20 years [29]. Notably, even though
prevalence rates are slightly higher using DSM-5 criteria
(presumably, due to the relaxed criteria for frequency and
duration of binge eating), effect sizes for impairment
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are also higher, suggesting that the revised criteria are
not identifying BED cases marked by less impairment
[29]. Although often thought of as a disorder common
among young women, BED prevalence among middleaged women (40–60 years) has a prevalence of at least
1.5%, with additional subthreshold cases being common
in this age-range; groups meeting full BED criteria and
subthreshold cases are both characterized by high levels
of distress and impairment [30].
Gender Differences
Men engage in overeating as much or more than women
but are less likely to endorse a loss of control and/or
distress associated with BE [28,31], and thus are less
likely to meet full BED criteria. However, when men do
meet criteria for BED, they experience as much clinical
impairment as their female counterparts [32]. Additionally, men’s BE may be more directly affected by body
image dissatisfaction than women’s BE, and although
it is associated with negative affect, it is less likely to be
associated with interactions between negative affect and
dietary restraint than seems to be the case for women
[33]. In addition, in the primary care setting, men with
BED were strikingly similar to their female counterparts
on most historical and developmental variables [33].
However, men reported more frequent strenuous exercise, whereas women reported that onset of overweight
and dieting occurred earlier in life [34]. That same study
observed that men (57%) were more likely than women
with BED (31%) to meet criteria for metabolic syndrome,
even after controlling for race and BMI. A second study
by the same research group again demonstrated that men
with BED are more likely to show elevated blood pressure, triglycerides, and meet criteria for metabolic syndrome, whereas women are more likely to have elevated
total cholesterol [35].
Race/Ethnicity
The evidence related to rates of BED among ethnic
minorities is equivocal, with some studies demonstrating that Caucasian women are more likely to experience
clinical levels of BED symptoms [36,37], others finding comparable rates between Caucasian and AfricanAmerican women [38,39], and still others discussing the
possibility of finding the greatest rates of binge eating in
ethnic minority samples [40], especially in light of the
high rates of obesity observed in some ethnic minority
groups [41,42]. Studies that focus on subclinical levels
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of eating pathology among undergraduate students are
most likely to find significant ethnic differences, while
studies of nonclinical samples utilizing diagnostic threshold find the fewest differences [43]. There is at least some
research demonstrating the highest rates of body image
disturbance or eating problems among Asian Americans
[44,45]. In addition, Latino individuals with BED may
have higher levels of ED-related psychopathology as compared with Caucasian individuals [46]. Finally, Caucasian
individuals who experience BED may be more likely to
utilize mental health services as compared with other
ethnic groups [47].
Age
Lower rates of BED have been documented in elderly
individuals relative to their younger counterparts in
population-based studies [28]. However, this may be
due to recall bias, birth cohort effects, restricted access
to studies, and/or increased medical morbidity leading to premature mortality [48]. Guerdjikova et al [48]
also noted that many treatment outcomes studies have
exclusion criteria related to age. This is unfortunate, as
elderly individuals and their younger counterparts appear
to exhibit similar levels of BE behavior, distress due to
BE, weight and shape concerns, psychiatric comorbidity,
and obesity. However, elderly individuals have reported
later onset, longer duration of illness, and less medical
morbidity [48]. In another study, Mangweth-Matzek et
al [30] surveyed women between the ages of 40 and 60;
they found that very few respondents met full criteria for
an eating disorder. However, when criteria were relaxed
(ie, dropping associated symptomology for BED and
frequency criteria for bulimia nervosa) an additional 4.8%
of the sample met criteria. Notably, women with subthreshold eating disorders reported very similar levels of
comorbid psychopathology as women whose symptoms
met diagnostic criteria.
• What tools are available for assessment of BED
in the primary care setting?
Two of the most commonly used questionnaires in
specialty clinics are the Eating Disorders Examination–
Questionnaire (EDE-Q [49]), and the Questionnaire on
Eating and Weight Patterns – Revised (QEWP-R [50]).
In the primary care setting, both appear to be low-cost
516 JCOM November 2015 Vol. 22, No. 11
and time-efficient methods of screening for BED. The
EDE-Q, however, may underestimate frequency of binge
eating episodes and overestimate the extent of eatingrelated pathology [51]. Notably, the QEWP has been
revised to reflect DSM-5 criteria and is available free of
charge (QEWP-5 [52]). The Binge Eating Scale [53]
is a 16-item scale often used to assess severity of binge
eating; it is free and easily accessible online. Regardless
of what measure is used, research indicates that a higher
proportion of people agree to having episodes where
they ‘‘lose control over eating’’ than when asked about
having episodes of ‘‘binge eating’’ [54], so asking about
loss of control over eating might be the more advisable
way to open the discussion with patients about their
eating behavior. In assessing for binge eating, physicians
should also be aware of some of the differences in clinical presentation observed for ethnic minorities (eg, lower
drive for thinness among African-American women) as
well as some research demonstrating that measures such
as the Eating Disorder Diagnostic Scale do not assess
equivalent constructs in African-American and Caucasian clients [55]. Finally, while self-report measures
often serve a practical function of quickly assessing a
large group, physicians may want to consider relying on
interview-based techniques for clients with lower levels of
education attainment and literacy; at least one study has
demonstrated problems with readability and comprehensibility with most BED measures [56].
Suggested interview questions to assess for BED in
primary care are presented in Table 2.
• What are the clinical features of BED?
BED and Obesity
The specific impact of BED on health is difficult to
separate from the impact of obesity on health, as the two
conditions frequently co-occur and are confounded in
many studies. Of relevance to the primary care setting,
many BED patients report gaining a substantial amount
of weight in the year prior to seeking treatment [57].
Although individuals with BED are often obese, proponents of classifying BED as a separate DSM diagnosis
argue that individuals with BED differ from their nonBED obese counterparts in regards to eating patterns,
eating disordered psychopathology, and associated features and comorbidities. Individuals with BED consume
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Case-based review
more calories in laboratory studies than weight-matched
controls [6,7,58]. In contrast, studies utilizing ecological
momentary assessment (ie, real-time assessments) found
no differences between BED obese and non-BED obese
participants in the frequency of self-reported binge eating
and caloric intake during binge eating episodes [59,60].
BED participants, however, were more likely to report
higher stress, desire to binge, negative affect, dietary
restraint, and being alone immediately before self-reported binge eating episodes. Furthermore, individuals with
BED also demonstrate more ED-related psychopathology than non-BED obese individuals [61–63]. Psychiatric
comorbidity is also higher among BED obese individuals
as compared their non-BED obese counterparts, and
the increased comorbidity is accounted for by the severity of binge eating as opposed to the severity of obesity
[6,64–67]. In addition, research demonstrates that obese
individuals with BED, as compared with non-obese BED
patients, have a poorer quality of life [68].
BED and Bulimia Nervosa
Numerous studies have supported the distinction
between bulimia nervosa and BED [69–76]. Diagnostically,
bulimia nervosa differs from BED by its requirement of
recurrent inappropriate compensatory behaviors in order
to prevent weight gain, such as self-induced vomiting;
misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise [3]. BED and bulimia nervosa are
distinguished by distinct risk factors, prevalence, course,
and treatment outcomes [28,67,77]. Individuals with
BED are less likely than individuals with bulimia to
diet before onset of the disorder, and fewer individuals
with BED cross over into other ED diagnostic categories [26,78–81]. Finally, BED and bulimia nervosa are
associated with different constellations of ED-related
symptoms and associated features [28,63,79]. For example, relative to BE patients, those with bulimia show
greater work impairment and psychiatric comorbidity
[28], higher dietary restraint and eating concerns [63],
and lower rates of obesity [79].
Psychiatric Comorbidity
BED is associated with poor social adjustment, greater
functional impairment, and significant psychiatric comorbidity, including overall distress and suicidality [67].
In a study of comorbidity with only selected disorders
(mood, anxiety, impulse-control, and substance use
disorder), 78.9% of individuals with BED had a lifetime
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Table 2. Suggested Interview Questions to Assess for
BED in Primary Care
Do you often eat in a 2-hour period what others might consider
an unusually large amount of food?
Do you often feel that you can’t control what or how much you
eat?
Over the past 3 months, how often have you eaten a large
amount of food and felt that you could not control what you
were eating? Over the past 3 months, have you made yourself vomit, took
laxatives, fasted, or exercised for more than an hour to avoid
gaining weight after overeating?
When you have eaten a large amount of food and felt out of
control doing so, did you…
• Eat much more rapidly than usual?
• Eat until you felt uncomfortably full?
• Continue eating even though you no longer felt physically
hungry?
• Eat alone because you felt embarrassed about how much
you were eating?
• Feel disgusted with yourself, depressed, or feel very
guilty after overeating?
How many times (when you weren’t sick) have you lost 20
pounds or more and gained it back?*
Over the past 4 weeks, has your shape/weight influenced
how you feel about (judge, think, evaluate) yourself as a
person?†
Note: Questions have been adapted for DSM-5 from Fairburn &
Beglin, 1994; Spitzer, Kroenke, & Williams, 1999; Spitzer, Yanovski,
& Marcus, 1993.
*Assesses severity of weight cycling [50], which is commonly associated with dieting and binge eating.
†Assesses overvaluation of shape/weight [41].
history of at least one comorbidity, 20.2% had one comorbid disorder, 9.8% had two, and 48.9% had three or
more [28]. Furthermore, the presence of current psychiatric comorbidity is associated with greater ED-related
psychopathology and associated distress [40,41]. The
most common comorbidities (lifetime rates) are specific
phobia (37.1%), social phobia (31.9%), major depressive
disorder (32.3%), post-traumatic stress disorder (PTSD)
(26.3%), alcohol abuse/dependence (21.4%), conduct
disorder (20%), attention-deficit/ hyperactivity disorder
(19.8%), illicit drug use/dependence (19.4%), and oppositional-defiant disorder (18%) [28]. A recent report supports that this level of comorbidity is evident in primary
care settings, noting that PTSD in particular is common
and associated with a host of other difficulties, including
depression, anxiety, drug use disorders, greater eating
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disorder pathology, and poorer psychological functioning
[82]. Personality disorders are also commonly comorbid
with BED, with the highest lifetime rates for avoidant
(11%), obsessive compulsive (10%), and borderline (9%)
personality disorders [83]. Finally, cigarette smoking is
also associated with binge eating [83,84], likely evolving
out of a weight-control smoking profile [85], and this is
of relevance to the primary care setting in that smokers
with BED gain more weight upon smoking cessation
than do their non-BED counterparts [86].
Further Evaluation
To assess behavioral factors related to obesity
and recent weight gain, the physician asks the
patient if she ever eats what would be considered an
unusually large amount of food for the circumstance.
The patient acknowledges that she does so regularly,
particularly in response to negative moods. The patient
also describes that these episodes contribute to ongoing
low mood, such that she feels highly depressed and hopeless following binge episodes. The physician then asks
about the patient’s exercise habits and weight management techniques. While the patient denies engaging in
compensatory behaviors (eg, vomiting, laxative use) to
counteract excessive eating, she does report a history of
dieting in which she dramatically restricts her food intake
and subsequently loses weight. The patient states that
these periods are inevitably followed by a resumption of
overeating, and she typically gains back more weight than
she originally lost. The patient estimates that she has lost
and regained more than 20 lb at least 5 times during her
lifetime. In addition, the patient reports difficulty maintaining a regular exercise regimen, especially since the
onset of osteoarthritis-related joint pain in the past year.
After the evaluation, the physician orders an electrocardiogram (ECG) and blood work. The ECG shows that
the P-wave, QRS, and T-wave axes are shifted leftward,
but within normal limits. A follow-up appointment is
scheduled in 2 weeks.
• What are the medical complications of BED?
BED is associated with numerous negative health sequelae including obesity, sleeping problems, musculoskeletal pain, joint pain, headaches, gastrointestinal
problems, menstrual problems, shortness of breath, chest
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pain, diabetes, low health-related quality of life, and
functional health impairments [87–90], with many of
these risks persisting even after controlling for BMI [91].
A 5-year follow-up of 134 individuals with BED and
134 individuals with no history of eating disorders,
who were frequency-matched for age, sex, and baseline
body mass index (BMI), provides further support that
BED confers risk of components of metabolic syndrome
beyond the risks associated with BMI alone [92]. Specifically, BED cases had higher longitudinal risk of
developing dyslipidemia, hypertension, type 2 diabetes,
any metabolic syndrome component, and two or more
metabolic syndrome components. Alarmingly, these
findings even emerge in studies of pediatric samples,
wherein BED predicts development of metabolic syndrome, elevated triglycerides, and increases in visceral
adiposity [93].
• What are risk factors for BED?
A number of risk factors for BED have been identified,
although many are risk factors for a number of psychiatric disorders and not specific to BED. These general risk
factors include depression/negative affectivity [94,95],
parental mood and substance use disorder, maternal
problematic parenting, and separation from parents [95].
A host of risk factors have been identified for disordered
eating, in general, including body dissatisfaction [94],
early onset of dieting [94], and perfectionism [96]. A
number of other variables are risk factors for both BED
and bulimia (but not anorexia), including a history of
childhood bully and teasing, negative self-evaluation,
parental depression, and negative family communication
about shape and weight [81,96]. In a study comparing
BED cases to psychiatric controls, childhood obesity, familial eating problems, family discord, and high parental
demands differentiated the BED cases [95]. In summary,
it has been suggested that BED risk is conferred by factors that increase risk of psychiatric disorder in general
and those that confer risk for obesity [81]. Of note, the
risk factors studied do not appear to differ between black
and white women [95].
Genetic risk factors appear to play a strong role in the
development of BED. Risk for BED tends to aggregate
in families independently of the risk for obesity, although
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crease risk for obesity [97]. Heritability estimates for
BED range from 45% to 57% [98,99], which is greater
than the heritability estimate for subthreshold binge eating (ie, overeating with a sense of loss of control, 41%)
[100]. In addition, symptom-level analyses support moderate genetic contributions for each BED symptom [98],
supporting the integrity of the diagnostic criteria. Finally,
shared environment appears to play a very small role in
the familial transmission of BED, and the contribution
of unique environmental factors in development of BED
appears to be substantial [97,101].
With regard to the neurobiological underpinnings of
BED, it appears that BED may be associated with hypersensitivity to reward, a phenomenon that is strongly
associated with the striatum and dopaminergic mechanisms [102,103]. In support of this hypothesis, Davis et
al [102] reported that BED was differentially related to
genotypes that reflect a greater density of D2 receptors
and higher D2 binding potential as compared to obese
controls. Additionally, greater increases in striatal DA
and unique activation patterns in the right ventral striatum have been demonstrated in individuals with BED
as compared to obese non-BED controls in response to
food-related stimuli [103,104]. Other findings have implicated the orbitofrontal cortex (OFC) in BED, which
is another brain region responsible for reward processing, particularly as it relates to the hedonic value of food
stimuli [103]. Increased volume of grey matter has been
documented in individuals with BED and bulimia as
compared to normal weight controls, and stronger medial OFC activation while viewing pictures of food was
observed in individuals with BED as compared to individuals with bulimia, overweight controls, and normal
controls [105].
Difficulties with affect regulation have also been implicated in the development of BED. Two theories that implicate a primary and specific role for affect regulation in BED
are cited most frequently in the extant literature: the affect
regulation theory and the escape theory. The affect regulation theory [106] posits that BE is a conditioned response
to negative affect which is correspondingly negatively reinforced by reductions in negative affect, which could occur
during or after BE. Escape theory [107] posits that aversive
self-awareness causes negative affect, which in turn triggers
BE. BE is then negatively reinforced by reductions in negative affect during a binge via an escape from self-awareness
that is accomplished through cognitive narrowing to the
immediate stimulus environment. In contrast to the affect
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regulation theory, escape theory predicts that negative
affect will increase after BE when self-awareness is restored. Results regarding changes in affect during BE
episodes are conflicting as to whether BE is associated
with decreases, no change [108–110], or even increases
in negative affect. In particular, a meta-analytic review of
36 studies that examined affect via ecological momentary
sampling found moderate increases in negative affect following binge episodes [111]. To some degree, results of
this meta-analysis may not generalize to BED, per se, given
that it included other binge eating groups, such as those
with bulimia nervosa. However, in general, studies suggest
that negative affect is an antecedent for BE and increased
negative affect may be a consequence of BE, at least among
women. More information is needed regarding aversive
self-awareness before and after BE, cognitive narrowing,
and changes in affect during BE. As such, the current
state of the literature provides only partial support for affect regulation models of BED in women. Furthermore,
it remains unknown if these results will generalize to
men.
Clinical Course
Evidence regarding the course and stability of BED is
conflicting and unclear. Several prospective studies have
suggested that BED is not a stable disorder, exhibiting
high rates of remission over time [26,99,112]. However, the samples have been criticized for being small,
completely female, younger than typical individuals with
BED, and post-ED treatment. In contrast, a prospective
study that included older women and a combination of
treated and untreated women suggested remission rates
at 1 year that were much lower (7%) [78]. Additionally, a
retrospective study [113] reported an average BED duration of 14.4 years. In a review of the studies cited above,
Wonderlich et al [6] concluded that “[a]lthough there
is variability in the data, it does appear that BED differs
from other eating disorders in terms of a greater tendency
toward recovery and fluctuation, although this may be
embedded in a chronic pattern of remission and relapse.”
Viewing BED as a disorder with a chronic pattern of
remission and relapse could explain why individuals with
BED retrospectively report a longer duration of illness, as
they may be more likely to conceptualize their illness as
one continuous course punctuated by different periods of
severity rather than several distinct bouts of BED. Finally,
although diagnostic crossover is a frequent phenomenon
among other eating disorders, the crossover rate for BED
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appears relatively low as compared to anorexia and bulimia [6,26,28,66].
Follow-up
Laboratory examination shows TSH levels within
normal limits and cholesterol levels of 48 mg/dL
(HDL), 162 mg/dL (LDL), and 270 mg/dL (total).
Triglyceride levels are 300 mg/dL and the patient’s fasting glucose level is 115 mg/dL. At the patient’s followup appointment, the physician states that a number
of laboratory results indicated negative weight-related
health consequences, including high cholesterol, high
triglycerides, hypertension, and probable pre-diabetes.
The patient initially disregards the significance of these
results, stating she only gained weight due to her breakup and quitting smoking, and she is motivated to diet
to lose weight in the near future. The physician asks for
more information about the patient’s eating behavior, in
particular asking if she ever feels as if she loses control
over her eating. The patient reluctantly admits to this,
and the physician provides a referral to a behavioral
health specialist. The patient expresses ambivalence and
a desire to try to manage her weight on her own. The
physician uses motivational interviewing techniques to
enhance motivation to follow up on this referral. In addition, the patient is encouraged to make small changes
to her diet and slowly increase her exercise by taking
walks. Another follow-up appointment is scheduled in
3 months.
• Which treatments are most effective for BED?
Despite the negative sequalae of BED, studies suggest
that it often goes untreated [114]. Women with BED, as
compared to women with anorexia and bulimia, are less
likely to seek treatment for BED and less likely to receive
treatment for their eating disorder when they do seek it
out [114–116]. Barriers to treatment may include shame
and internalized weight stigma, lack of knowledge about
where to seek treatment, a belief that willpower should be
sufficient to overcome the problem, lack of understanding that BED is a psychiatric disorder, finances/insurance barriers, and lack of BED detection by non-specialist
treatment providers [115]. These barriers are particularly
concerning, as women with BED report greater health
care utilization and comprise a large segment of patients
520 JCOM November 2015 Vol. 22, No. 11
in weight control programs. Therefore, it appears individuals with BED seek help for the negative consequences
of the disorder, but they are less likely to seek and receive
help for the likely root cause of their concerns. This is a
particularly damaging pattern, as the presence of BED
may negatively impact the outcome of obesity treatment
[117]. There are, however, a number of promising treatments for BED, as described below:
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is generally considered to be the most well-established and empirically
supported treatment for BED [118,119]. The cognitive
behavioral conceptualization of BED is based on Fairburn, Cooper, and Shafran’s [120] transdiagnostic model
of eating disorders (CBT-E), which is an expanded
version of the cognitive behavioral model of bulimia
nervosa [121]. CBT-E posits that the core pathology in
eating disorders is a dysfunctional system in which selfworth is based on eating habits, shape, or weight, and the
individual’s ability to control them. Attempts to maintain
self-worth by controlling eating, shape, and weight result
in extreme and brittle forms of dietary restraint. Inevitable violations of the individual’s dietary rules are then
interpreted as lack of self-control, leading to a temporary
abandonment of dietary restraint and consequent BE.
These dietary slips and corresponding BE often occur in
response to acute changes in mood, and BE is thus negatively reinforced by “neutralizing” negative mood states.
Lapses in dietary restraint also result in secondary negative self-evaluation, which serves to further exacerbate a
cycle of increased dietary restraint to improve self-worth
and then inevitable dietary lapses leading to BE. CBT-E
expanded upon CBT-BN by postulating 4 processes that
maintain ED: severe perfectionism (clinical perfectionism), unconditional and pervasive low self-esteem (core
low self-esteem), difficulties coping with intense mood
states (mood intolerance), and developmental interpersonal difficulties (interpersonal difficulties). Of note, the
CBT-E model explicitly states that individuals may differ
in the extent to which they experience the 4 maintaining
processes and not every individual will experience all four.
Overall, treatment is focused on normalizing eating
patterns (ie, not weight loss), cognitive restructuring
for weight/shape concerns and other triggers for binge
eating, and relapse prevention [122]. CBT has produced
substantial reductions in binge eating as compared to
no treatment [123–125] and supportive therapy [126].
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Case-based review
The majority of RCTs have reported remission rates greater than 50% [127]. Unfortunately, CBT has generally not
produced meaningful weight loss [118,122,127–129],
but this may be a contraindicated goal. CBT has demonstrated improvements in a number of features associated
with BED including eating disordered psychopathology
[122,124,130,131], depression [122,124,130,132], social adjustment [133], and self-esteem [132]. Treatment
gains are generally well-maintained at 1-year to 4-year
follow-up [122,123,130,133,134]. Individual and group
treatments appear to produce similar results [134], and
treatment completion rates have been estimated at approximately 80% across different delivery formats [127].
One strength of the CBT literature is the inclusion of
participants with severe psychopathology, which facilitates the generalizability of these findings [127].
A number of factors have been associated with treatment outcome in CBT trials. Poor treatment outcomes
have been associated with a history of weight problems
during childhood, high levels of emotional eating at
baseline, interpersonal dysfunction, and low group cohesion during group CBT [110,124,134]. Overvaluation of
weight and shape demonstrated a statistical trend toward
negatively impacting outcomes in one study. The presence of a cluster B personality disorder (ie, borderline histrionic, antisocial, and narcissistic personality disorders)
predicted higher levels of binge eating at 1-year follow-up
in a combined sample of participants treated with group
CBT or group interpersonal psychotherapy (IPT) [135].
Alternatively, positive treatment outcomes have been
associated with low levels of emotional eating at baseline,
older age of onset, weight loss history that is negative for
amphetamine use, and decreases in depressive symptoms
during treatment [124,134,136,137]. In addition, early
response to treatment (defined as a 65%–70% reduction
in binge eating within 4 weeks of starting treatment)
tends to be associated with greater long-term (ie, 1–2
year) remission from BED and lower eating disorder psychopathology, across a variety of psychological treatment
approaches [138–144].
Interpersonal Psychotherapy
IPT for BED was adapted by Wilfley and colleagues [145]
from IPT for depression, and the rationale for its use with
BED is based on successful outcomes for individuals with
bulimia and multiple studies documenting interpersonal
deficits in individuals with BED [146]. IPT seeks to
address interpersonal problems in 4 areas: interpersonal
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conflict, grief, role transitions, and interpersonal deficits
[135]. While adapting IPT for BED, it was noted that
the course of BED tends to be more chronic than the
course of depression, thus the focus of IPT for BED was
shifted from addressing the interpersonal precipitants of
the disorder to the interpersonal factors that maintain the
disorder [145]. Fewer studies examining the effectiveness
of IPT in treating BED have been published than those
examining CBT for BED, but it appears that IPT is as
efficacious as CBT immediately post-treatment [130],
and at 1- [130] and 4-year follow-up [147]. In addition,
at least 2 studies have been published that compare IPT,
cognitive behavioral therapy–guided self-help (CBTgsh),
and behavioral weight loss [133,141]. Overall, results
support the use of both IPT and CBTgsh (discussed in
more detail below), with important moderators of treatment effects observed. For example, Wilson et al [133]
found that clients with higher levels of psychopathology
were better suited for IPT. The authors conclude that
these results could inform a model of evidence-based
stepped care, where CBTgsh, a low-cost, low-intensity
treatment, should be considered as the first line of treatment. Secondarily, IPT, which represents a more specialized and expensive form of treatment, could be considered the next level of care, particularly for clients who
are not demonstrating rapid improvement in response to
CBTgsh.
Dialectic Behavior Therapy
A small number of studies have investigated the treatment of BED with dialectical behavior therapy (DBT).
Originally developed to treat borderline personality disorder [148], DBT is of particular interest given its explicit
targeting of emotion regulation. According to the DBT
model of BED [149], emotional dysregulation is the core
psychopathology in this disorder, and binge eating is
viewed as attempts to influence, change, or control painful emotions. Initially, promising results were published
showing positive treatment effects in an uncontrolled
study [150] as well as wait-list controlled trials [151].
Notably, relative to wait-list controls, participants in a
DBT guided self-help program (who received an orientation, DBT manual, and six 20-minute support calls
across 13 weeks) reported reduced past-month binge
eating, higher binge eating abstinence rates, and over the
longer term improved quality of life and reductions in
ED psychopathology. However, a comparison of DBTBED with an active comparison control group (ie, non-
Vol. 22, No. 11 November 2015 JCOM 521
Binge-eating disorder
specific supportive therapy) failed to find significant differences between the 2 treatments (defined as effect size
greater than 0.5) at 12-month follow-up in binge eating
abstinence, binge eating frequency, most ED-related
psychopathology, positive affect, depression, and selfesteem [152]. Therefore, DBT may have potential and, at
a minimum, is equally efficacious as supportive therapy.
Mindfulness- and Meditation-Based Therapies
Treatment outcome studies utilizing mindfulness-based
therapies, including mindfulness-based stress reduction
(MBSR) and acceptance and commitment therapy (ACT),
make up a small but promising body of literature. Reasoning that negative affect, eating in the absence of hunger,
and emotional eating may comprise one pathway to
binge eating [153,154], it follows that mindfulness-based
therapies may act through their effects on emotion regulation, acceptance strategies for tolerating negative affect,
and awareness of bodily cues. A recent review identified
19 studies exploring the effects of mindfulness-based
interventions on binge eating severity and frequency as
well as a number of related indicators, observing positive
effects for this form of treatment [155]. For example, MBEAT [156] is a group treatment for BED that is primarily based on MBSR. Treatment is targeted at cultivating
mindfulness, mindful eating, emotional balance, and
self-acceptance[157]. The treatment also places particular
emphasis on developing self-awareness of internal hunger
and satiety cues. A recent randomized controlled trial of
MB-EAT produced significant improvements in binge
eating frequency and BE-related psychopathology [158].
Furthermore, process variables including hunger awareness, satiety awareness, and mindfulness were correlated
with positive outcomes. In addition, a small study (n = 39)
that compared ACT to standard follow-up utilized by a
bariatric surgery team demonstrated significantly greater
improvements in disordered eating, body satisfaction, and
quality of life for clients who participated in ACT [159]. In
brief, results suggest that mindfulness-based interventions
represent an additional treatment approach with supporting but limited evidence to date.
Self-Help Interventions
Self-help interventions for BED are categorized as pure
self-help or guided self-help. In treatment outcome studies, pure self-help is generally conducted with a self-help
manual, although several studies have examined more
novel formats such as the internet, video, and CD-ROM.
522 JCOM November 2015 Vol. 22, No. 11
GSH also uses a self-help manual (or other format) with
the addition of brief sessions with health care providers
who have varying degrees of expertise with the type of
therapy being utilized. CBT is the most commonly utilized therapeutic modality in treatment outcome studies
of self-help interventions, and they most often utilize
Fairburn’s Overcoming Binge Eating self-help manual
[160].
Two studies have directly compared pure and guided
self-help with Fairburn’s manual and produced conflicting results. Carter and Fairburn [161] found that in a
sample of primarily white women with BED, pure selfhelp (CBTsh; n = 24) and guided self-help (CBTgsh;
n = 24) were equally effective, and both were superior
to wait-list controls at 6-month follow-up in producing
BE abstinence (CBTsh = 40%, CBTgsh = 50%), reducing
binge eating, ED-related psychopathology, and general
psychiatric symptoms. In contrast, a study comparing
CBTsh and CBTgsh in 40 primarily white women with
recurrent binge eating (82.5% diagnosed with BED),
guided self-help was superior to pure self-help at the end
of treatment in reducing BE frequency, eating concern,
and restraint [162]. CBTgsh and CBTsh were equally
effective in producing BE abstinence (50% and 30%,
respectively), and reducing shape concern, weight concern, and general psychiatric symptoms [162]. Higher
levels of general psychiatric symptoms were predictive of
higher BE frequency post-treatment for both treatments.
It should be noted that participants in both conditions
experienced statistically significant improvements on all
variables as compared to baseline.
CBTgsh also performed as well or better than individualized treatments in one study [133]. CBTgsh, IPT, and behavioral weight loss (BWL) were compared in a large study
of 205 primarily white, obese or overweight individuals diagnosed with BED. The 3 treatments produced equivalent
outcomes for binge eating at post-treatment, but BWL produced significantly greater weight loss. However, at 2-year
follow-up, the CBTgsh and IPT groups had maintained
treatment gains and were significantly superior to BWL in
reductions in binge eating. The 3 groups were equivalent
with regard to weight loss at the 2-year follow-up, and
none reported clinically significant weight loss. Of note, as
compared to the IPT and BWL groups, the CBTgsh group
received 10 sessions as opposed to 20, received 25-minute
sessions as opposed to 60-minute sessions, and were treated
by providers with limited levels of experience as opposed to
doctoral-level clinical psychologists.
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Case-based review
To summarize, CBT is the most often studied type of
self-help treatment. Both CBTsh and CBTgsh produced
improvements in binge eating and associated psychopathology as compared to baseline and wait-list controls,
and treatment gains were maintained at 6-month followup. Conclusions regarding the relative superiority of pure
self-help or guided self-help are premature given the
small number of studies and conflicting results.
In addition, limited information is available regarding
moderators and predictors of guided self-help outcomes.
Masheb and Grilo [163] performed a cluster analysis of
the sample for the CBTgsh vs. BWLgsh described above
[164] and identified 2 clinically significant subtypes: a
dietary-negative affect subtype characterized by high
restraint, low self-esteem, and depressive symptoms; and
an overvaluation of weight and shape subtype. For both
the CBTgsh and BWLgsh groups, the dietary-negative
affect subtype experienced higher levels of binge eating
frequency, and the overvaluation of weight and shape
subtype experienced higher levels of ED-related psychopathology. Additionally, individuals receiving BWLgsh
who experienced a rapid response to treatment reported
lower BE frequency, greater weight loss, and higher restraint than participants without a rapid response [142].
In contrast, rapid response did not appear to affect outcomes for CBTgsh participants. Finally, the combination
of low self-esteem and high ED-related psychopathology
negatively affected BE remission rates for CBTgsh recipients [133].
Pharmacologic Treatment
Currently only one medication, lisdexamfetamine dimesylate, has been FDA-approved for the treatment of BED.
Previously approved for treating both adults and children
with attention-deficit hyperactivity disorder, lisdexamfetamine dimesylate is a central nervous system stimulant
and has been found to significantly reduce number of
binge days, with robust effect sizes [165]. Beyond this
medication, the evidence for pharmacologic treatment of
BED is limited. A recent review identified only 22 studies exploring the effects of pharmacologic treatment in a
methodologically rigorous way (eg, double-blind placebo
design) [4]. To date, a number of different medication
classes have been evaluated, including antidepressants,
anticonvulsants, stimulants, anti-obesity drugs, and others. Overall, there is some evidence that antidepressant
and anticonvulsant agents are efficacious at reducing BE
frequency [166,167] and sometimes effective regarding
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statistically significant weight loss [168,169]. However,
the majority of results are generally disappointing, both
with respect to reductions in binge eating and sustained
weight loss [48,170,171]. In addition, there are serious
limitations in the literature that must be considered,
including the limited number of studies that address
the high placebo response observed in clinical samples,
limited follow-up windows, and inadequate multiplicitious confirmatory trials. Despite these limitations, the
evidence base related to pharmacologic treatment is continuously evolving and represents an important future
direction for the treatment of BED.
Treatment
Prior to her next medical follow-up, the patient
meets with a psychologist. The patient discloses
that she has been binge eating several times per week
for over a year; she also discloses a history of prolonged
sexual abuse perpetrated by a step-parent during her
childhood. When the patient returns to her follow-up
medical appointment, she reports that her psychologist
has diagnosed her with BED and PTSD. She states that
they are using cognitive behavioral techniques to regulate her mood and eating behavior, with a specific aim
of avoiding excessive dietary restraint. In addition, they
are working together to discuss her unfulfilling romantic
history and processing her experiences of trauma. Since
her last appointment with the primary care physician, she
reports an increased awareness of her eating habits, improvement in mood, and a 10-lb decrease in her weight.
The patient reports that she has continued to meet
weekly with her psychologist and has slowly begun
reintroducing low-impact exercise to her routine. She
continues to lose weight gradually, but with a priority of
stabilizing eating behavior and avoiding binge episodes
versus aiming for weight loss. She reports that her mood
has stabilized. Her cholesterol and triglycerides remain
high, but her blood pressure is controlled effectively
with medication. Her physician recommends continued
psychological treatment, periodic meetings with a nutritionist, and prescribes medication for her cholesterol. A
follow-up appointment with her physician is scheduled
in 6 months.
Summary
BED is the most common eating disorder, but one for
which many do not seek treatment directly, instead presenting to primary care for a host of comorbid psychiatric
Vol. 22, No. 11 November 2015 JCOM 523
Binge-eating disorder
Table 3. Information Resources
Binge Eating Disorder Association
• http://bedaonline.com
National Eating Disorders Association
•
http://www.nationaleatingdisorders.org
Alliance for Eating Disorders Awareness
•
http://www.allianceforeatingdisorders.com
and medical conditions. Proper screening and referral
in the primary care setting can optimize the likelihood
of patients’ obtaining empirically supported treatments
with coordinated care between primary care and behavioral health providers. Some sources for information for
patients and providers are listed in Table 3. As the literature does not yet overwhelmingly support a particular
treatment modality over another, the primary care physician should support patient preferences amongst the options reviewed above. Given that a large body of literature
supports the use of motivational interviewing strategies
[172,173] to optimize the likelihood of engaging in a
wide range of health behaviors in the primary care setting, reliance on such strategies to promote engagement
in BED treatment is highly recommended.
Corresponding author: Karen K. Saules, PhD, Eastern
Michigan University, Psychology Clinic, 611 W. Cross St.,
Ypsilanti, MI 48197, [email protected]
Financial disclosures: None.
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