What's the Best Treatment for Binge Eating Disorder?

Researchers debate whether to tackle psychological or weight issues first

(March 2002) -- Perhaps the greatest controversy in the field of eating-disorder treatment is the debate over how to treat binge-eating disorder. The condition--currently a provisional category in the Diagnostic and Statistical Manual--is marked by recurrent binge-eating without purging and is typically seen in people who are obese.

Like people with bulimia nervosa, those with binge-eating disorder carry distorted attitudes about eating, shape and weight, as well as mood symptoms such as depression and personality disorders. The disorder affects about 2 percent of the general population and 8 percent of people who are obese.

Because binge-eating disorder involves both weight and eating-disorder concerns, researchers in both the obesity and eating-disorders fields perceive treatment goals through the lens of their own training. On one side of the debate, eating-disorders experts believe binge-eating is best treated by traditional eating-disorder approaches, such as helping patients reduce or eliminate bingeing, improving their self-esteem and body acceptance, and treating underlying psychological problems such as depression and anxiety.

On the other side, obesity experts maintain, it's better to treat the obesity first. They believe that tackling psychological problems without addressing excess weight puts the cart before the horse.

"Public health experts who deal with obesity would say, 'If you're not treating the weight, it's like helping someone get rid of a hangnail and leaving the cancer,'" says Kelly Brownell, PhD, a psychologist who heads the Yale Center for Eating and Weight Disorders and treats people with binge-eating disorder and obesity. "Binge-eating itself is not of public health significance--eliminating it does not address all of the potential long-term sequelae of obesity such as hypertension, stroke and heart attack."

Because the disorder is multifaceted, there are numerous tacks to treat it, believes Columbia University psychiatrist B. Timothy Walsh, MD, who chaired the DSM-IV working group on eating disorders. For example, the literature shows that cognitive behavioral therapy is useful for depression and bulimia, that interpersonal therapy aids depression, and that behavioral weight-loss management can help treat obesity.

"There's a lot going on when you're trying to look at the utility of these interventions," Walsh says. "For many people with binge-eating disorder, you can think of at least three potential targets, and it's not clear whether you should aim at all of them at the same time."

Managed care can make matters worse, he says, because it may only pay for one approach when more may well be needed.

What Should Treatment Target?

Clinicians who treat binge-eating disorder as an eating disorder say that addressing the specific and general psychopathology that underlies the condition eliminates binge-eating and helps patients feel better about themselves. Treatments that fall into this camp include cognitive behavioral therapy, which addresses a person's thoughts and behaviors about eating and self-image, and interpersonal psychotherapy, which helps a person face and heal rifts in current relationships.

As an example of the effectiveness of interpersonal therapy in treating binge-eating disorder, Denise Wilfley, PhD, a binge-eating disorder expert at San Diego State University, describes a woman she helped using this treatment: The woman had been living in another country, and once she returned to the United States, lost all of her social support. She began to binge-eat, and in addition, developed major conflicts with her son, which added to her level of distress.

In a study now in press in the Archives of General Psychiatry, Wilfley shows how this might come about. The study, the largest on binge-eating disorder to date, compares outcomes of 162 overweight binge-eating disorder patients. Half received group cognitive behavioral therapy and half received interpersonal therapy. Both therapies showed high long-term success in reducing binge-eating and treating a range of psychological problems.

And for 25 percent of the sample, the therapies also helped reduce weight: Participants who abstained from binge-eating at post-treatment and maintained abstinence at a one-year follow-up lost weight, while those who continued to binge-eat gained weight.

continue: Two Types of Binge Eaters?

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Reviewed: 03/2006