Binge Eating Disorder

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Binge eating disorder is generally treated with similar therapies to bulimia nervosa, including cognitive behavioral and interpersonal psychotherapy and antidepres-sant medications. Any consideration of the treatment of binge eating disorder must begin with recognition of the unusual instability of the disorder. As Fairburn et al. (120) have noted, ''unlike bulimia nervosa, binge eating disorder is an unstable state with a strong tendency toward spontaneous remission.'' In one study, a 4-week placebo run-in revealed a decrease in the frequency of binge eating of 70% (from 6.0 to 1.8 binge episodes per week) (121). Alger et al. (122) showed a similar 68% placebo response. Even in a wait-list control, binge eating decreased by 38% during a 3-month period.

1 Psychotherapy and Weight Loss Treatment

Both CBT (100,123) and IPT (100) have been shown to promote reductions in binge eating for up to 12 months following treatment. Treatment is generally similar to that used for bulimia nervosa, with some modifications. It has been hoped that, as these psychotherapies may work through differing mechanisms, patients failing to improve with one form of psychotherapy might respond favorably to another. However, a study using IPT as ''salvage'' therapy for patients who failed to respond to CBT found no additional benefit of IPT in this group (124). Another form of psychotherapy, dialectical behavior therapy (DBT), has recently been adapted for use in binge eating disorder (125). DBT is an empirically validated treatment for individuals with borderline personality disorder, which conceptualizes pathologic behaviors as faulty attempts at affect regulation (126). The | treatment attempts to teach clients more functional methods of dealing with negative emotions.

Because many patients with BED are obese, and because eating disorder treatment alone does not lead to weight loss, researchers have sought to determine whether those with BED can lose weight with tradi-

tu tional weight loss treatments. Perhaps because of the instability of the diagnosis of BED, most studies find that, in the short term, binge eaters can lose weight well in standard weight loss treatment programs that don't I

address binge eating (127-130), although some studies have found a greater risk of dropping out of treatment or earlier regain of lost weight (130-132). One study, however, has found less frequent treatment attrition among obese women with binge eating disorder than among those without the disorder (133), while another has found episodic overeaters, who do not experience feelings of loss of control, to be at risk for attrition (134).

A frequent concern in using calorie-restricted diets in obese patients is that such dietary restriction will trigger the onset of binge eating in those who have not previously experienced this problem and will worsen binge eating in those already affected. Although one study found that a third of nonbinge eaters reported episodes they labeled as ''binges'' after a very low calorie diet program (135), others have found that weight loss treatment actually improves binge eating and associated psychopathology over the short term (37,38,127) and does not induce binge eating in obese subjects who previously reported no difficulties in this area (38). A recent review of the literature concluded that weight loss treatment does not have an adverse affect on binge eating in patients with binge eating disorder (34).

Sequencing of treatment for the eating disorder and obesity has been proposed an one possible means of improving outcome in patients with both binge eating disorder and obesity. One study that treated 93 obese women diagnosed with BED with a sequence of CBT followed by behavioral weight loss treatment found that, on average, weight lost during the weight loss treatment phase was not maintained. However, those who stopped binge eating during the CBT phase were able to maintain a weight loss of 4.0 kg over the follow-up period, suggesting that successful elimination of binge eating may improve long-term weight maintenance (136).

2 Medication

Antidepressant medication is frequently used in the treatment of binge eating disorder, although few studies of its efficacy have been published (107). Agras et al. (127) found that adding desipramine to a combination of CBT and behavioral weight loss treatment did not provide any additional benefit in reduction of binge eating. However, those on medication did maintain a significantly larger weight loss at 3-month post-treatment follow-up, as well as favorable reductions in disinhibition.

Fluoxetine has been evaluated as a weight loss agent in a group of obese individuals that included binge and nonbinge eaters (137). That study demonstrated significant weight loss in both groups while medication was continued, but no differential advantage was found for binge eaters. The effects of fluoxetine on binge eating frequency or severity were not measured. A small open-label trial using a combination of phentermine and fluoxetine as an adjunct to a 20-week CBT program showed significant reductions in binge frequency and distress, along with significant weight loss, at the end of the active treatment period. Medication duration was variable (1-25 months), and only 25% of patients continued taking medication throughout the study and follow-up periods. However, most of the weight was regained by 18-month follow-up, and the authors concluded that addition of phentermine/fluoxetine to CBT had little long-term benefit (138).

A report of an 8-week, double-blind, placebo-controlled trial using dexfenfluramine in obese individuals with binge eating disorder found significant decreases in binge frequency in the active treatment group compared with placebo, although neither group lost weight during the treatment period (121). Another open-label trial using the fenfluramine/phentermine combination found that after 24 weeks of treatment, binge eaters improved eating patterns and depression scores, and achieved similar weight loss to nonbinge eaters (139). Although fenfluramine and dexfenfluramine were withdrawn from the market due to their implication in the development of valvular heart disease, currently available weight loss medications are being studied in populations with binge eating disorder.

A few preliminary studies have suggested that opiate antagonists such as naltrexone (122,139,140) or nalox-one (72) may eventually play a role in the treatment of binge eating disorder, but such approaches are still experimental.

3 Self Help

A cognitive behavioral self-help program for binge eating, either used alone or with guidance, has been found to be useful. The frequency of binge eating during a 12-week study fell by 53% in the pure self-help condition, significantly more than the 38% fall in the wait-list control group (P<.05) (141). Use of a self-help | manual for binge eating has also been shown to improve eating behavior, reduce shape and weight concerns, and improve general psychological functioning in obese women with binge eating disorder (142). |

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