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The pattern provides a clue for further interventions, Wilfley believes. "If we help people eliminate binge-eating patterns, it should have an impact on body weight," she notes.

Researchers who are more concerned with obesity, however, argue it's not enough to make weight loss a side issue that may or may not get addressed. The way to go, they believe, is behavioral weight loss, which is usually less expensive, shorter in duration and directly targets obesity.

These researchers make a mirror argument to Wilfley's comments about eating-disorder treatments.

"People who use behavioral weight-loss treatments say that it does eliminate binge-eating--and there is some evidence for this," says G. Terence Wilson, PhD, a psychologist at Rutgers University who was a member of the DSM-IV working group on eating disorders.

It's also true, however, that many obesity treatments don't hold up in the long run.

"There is really no good treatment for obesity," maintains Christopher Fairburn, MD, a psychiatrist and eating disorders expert at the University of Oxford. "Surgery is possibly the best, but it's pretty radical. Drug treatments help about 5 percent of people, but you have to keep taking them indefinitely. And behavioral therapies...everyone relapses," he says. "The psychology of it is very interesting," Fairburn adds. "Losing weight is quite easy. But people can only keep it up for a while, then they tend to just throw in the towel."

But Brownell counters that some programs do work, especially if they include a strong weight-maintenance component. "The estimates are far too pessimistic on weight loss," he argues.

A Clinically Troubled Subgroup

There's yet another wrinkle in the binge-eating disorder debate: Researchers and clinicians are starting to discover that there are probably two groups of binge-eating disorder patients, one that has disordered eating and obesity but less serious psychological problems; another that displays those same eating disturbances but has more long-term, entrenched psychological difficulties.

A recent study by Yale University psychologist Carlos Grilo, PhD, and colleagues confirms the existence of such a group. In the December 2001 issue of the Journal of Consulting and Clinical Psychology (Vol. 69, No. 6), he and colleagues report that about a third of the 101 binge-eating disorder patients in the study--those who generally showed greater negative affect--also demonstrated more severe eating-related psychopathology and had greater psychological disturbances than the rest of the group. That effect held up over time, Grilo notes in the article, adding to the probability that this is a bona-fide subtype of the disorder.

"There may well be subgroups of patients with high rates of depression and low self-esteem who need specialized treatment," says Wilson. "Others who don't have that degree of pathology might just need behavioral weight loss treatment."

Best Of Both Worlds?

Meanwhile, some researchers are looking at ways to develop a treatment approach that includes both weight-loss and psychological components.

Research conducted by Stanford University psychiatrist Stewart Agras, MD, for example, shows this may be possible. In a 1997 study reported in the Journal of Consulting and Clinical Psychology (Vol. 65, p. 343-347), he found that people who abstained from binge-eating following specialty eating-disorder treatment were significantly more likely to benefit from weight-loss treatment in both the short and long run.

Some of the questions troubling the field may be addressed in a study planned by Wilfley, Agras and Wilson. Now submitted as a grant proposal to the National Institute on Mental Health, the study plans to compare the effects of three divergent treatments that represent the field's areas of controversy: interpersonal psychotherapy, behavioral weight-loss treatment and a guided self-help intervention developed by Fairburn that's intended to provide a credible, inexpensive treatment alternative. Besides looking at binge-eating and body weight, the study will compare how the treatments affect the subgroup of binge-eating disorder patients with high negative affect noted in Grilo's study.

The debates in the field may simmer down once more data are in, Wilfley comments.

"We're a very young area," she says. "We need the next generation of research to help answer some of the questions that are plaguing our field."

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Reviewed: 03/2006