By Michele D. Levine, PhD and Marsha D. Marcus, PhD
Western Psychiatric Institute & Clinic • University of Pittsburgh Medical Center
Reprinted from Eating Disorders Review
July/August 2003 Volume 14, Number 4
©2003 Gürze Books
Binge eating disorder (BED) is characterized by recurrent, persistent episodes of binge eating that occur without regular compensatory behaviors intended to prevent weight gain. Thus, BED is classified in the Diagnostic and Statistical Manual of Mental Disorders IV as an eating disorder not otherwise specified and listed in an appendix as a diagnosis requiring additional study.
The prevalence of BED among the general population is approximately 1% to 2%; however, the rate of BED among individuals seeking treatment for obesity is considerably higher: It is estimated that as many as a third of individuals who present for treatment in university-based weight-control clinics report significant binge eating. Thus, BED is the one of the most common forms of disordered eating, and the search for efficacious treatments is an ongoing goal.
Not surprisingly, treatments designed for individuals with BED have been adapted from those that have effectively reduced binge eating among individuals with bulimia nervosa (BN). Current treatments include psychotherapy, drug therapy, and combinations of the two. This article provides an update on psychological treatments for BED and reviews the rationale and support for these treatments.
Cognitive Behavioral Therapy
To date, cognitive behavioral therapy (CBT) is the most extensively studied treatment for individuals with BED. CBT for BED is based on a cognitive-behavioral model of binge eating. This model postulates that binge eating develops in response to restrictive food intake and occurs in the context of ongoing dietary restraint and the experience of negative emotions.
CBT for binge eating focuses first on helping patients normalize eating, then turns to identifying and restructuring maladaptive thoughts and beliefs, particularly those related to eating, body shape, and weight. CBT has consistently been shown to be more effective than no treatment in decreasing the frequency of binge eating and in improving the psychopathology associated with binge eating. In addition, although the effect of CBT on weight loss has varied, most individuals who abstain from binge eating seem to lose at least some weight over the longer term.
Differences between individuals with BED and BN. CBT for BED also has been adapted to reflect differences between individuals with bulimia nervosa and those with BED. Specifically, cognitions relating to having a large body size can be directly targeted in treatment. Overweight individuals with BED may be helped to accept their body size and to restructure maladaptive thoughts about the amount of weight loss they are likely to achieve. That is, although modest weight loss may relate to improvements in binge eating, for most BED patients this decrease may not correspond with their desired weight loss. It is therefore important that cognitions about acceptable body sizes be targeted during treatment.
Another adaptation of CBT for BED relates to differences in the role of dietary restraint and weight-control efforts between individuals with BED and those with BN. Although the cognitive behavioral theory of BN stresses the role of restraint in precipitating binge episodes and treatment focuses on decreasing dietary restraint, patients with BED do not necessarily binge-eat in response to restraint or hunger. Indeed, the preponderance of evidence suggests that dieting is not contraindicated among individuals with BED, and that increasing the level of dietary restraint or dieting may help to ameliorate binge eating.
Related to the benefits of moderate, health-oriented dietary restraint, it is worth noting that standard behavioral weight control can be an effective treatment for BED. In spite of early speculation, the focus on decreasing caloric intake and increasing dietary restraint in a weight-control program does not exacerbate binge eating. In fact, behavioral treatment for obesity has helped ameliorate binge eating in BED patients. Thus, treatment approaches that focus on modest calorie restriction, that provide education about sound nutrition principles, and that promote moderate exercise may decrease binge eating behavior and, as a corollary, may be associated with weight loss among obese individuals with BED.
Interpersonal Psychotherapy (IPT) also has received empirical support in the treatment of individuals with BED. Like CBT, IPT is a structured, focused, and time-limited treatment, and the rationale for its use among individuals with BED stems from its efficacy in decreasing binge eating among individuals with BN. IPT for binge eating is based on the idea that binge eating occurs in the context of specific social and interpersonal problems. Treatment thus focuses on identifying and addressing specific, problematic interpersonal patterns, in an effort to ameliorate dysfunctional eating behaviors. IPT for BED does not directly target eating behaviors or attitudes about eating, shape, and weight.
Both approaches reduce binge eating. Although the rationale for CBT and IPT differs, recent research has shown that both approaches are associated with significant reductions in the frequencies of binge eating among individuals with BED. Wilfley and her colleagues (2002) compared the outcome of overweight individuals with BED who received group IPT to individuals treated with group CBT. Both treatment approaches were associated with significant reductions in binge eating and general psychopathology and increases in self-esteem. Moreover, changes in binge eating, dietary restraint, and thoughts about shape and weight were maintained during a one-year follow-up period. Thus, CBT and IPT appear to be equally effective in the treatment of BED, although the mechanisms by which they promote changes in eating behavior differ.
Dialectical Behavior Therapy
Recently, an approach originally designed for the treatment of individuals with borderline personality disorder has also shown promise in the treatment of persons with BED. Dialectical behavior therapy (DBT), developed by Marsha Linehan, is a comprehensive treatment program based on cognitive and behavioral principles and complemented by the use of acceptance-based strategies derived primarily from Zen Buddhism. In addition to weekly individual outpatient treatment, traditional DBT prescribes a weekly skills group in which the goal is to increase participant’s behavioral skills. (For more information, please see Dr. Linehan’s book, Cognitive Behavioral Treatment of Borderline Personality Disorder , and her manual, Skills Training Manual for Treating Borderline Personality Disorder .)
Using Linehan’s DBT skills manual as a base, Telch and her colleagues (2001) have adapted and tested a group-based version of DBT for individuals with BED. This program has been effective for decreasing binge eating behavior and maladaptive attitudes about eating, shape, and weight. In addition to this initial empirical support, several other features of DBT may make it particularly useful for treating BED.
Difficulties with change, ambivalence about changing behaviors. First, DBT is based on a dialectical world view, which recognizes and accepts the difficulty of change, and the ambivalence individuals may have about modifying or relinquishing eating disorder symptoms. This philosophy provides a positive and constructive means to understand difficult behavior, and the deliberate balance of acceptance and change strategies can reduce ambivalence about treatment.
Second, DBT encourages a compassionate, nonjudgmental stance. Because binge eating and its associated symptoms can be perplexing, confounding and shameful for patients, the conscious attempt on the part of clinicians who work with these individuals to understand that these symptoms are valid efforts to cope with aversive circumstances helps to establish and maintain an effective working relationship. Finally, the language and philosophy of DBT can be disseminated both to other health-care staff who work with patients and to patients’ families. Thus, DBT is another approach to treating BED, and additional research is needed to determine its efficacy relative to that of CBT and IPT.
CBT and IPT are effective for reducing the frequency of binge eating and associated psychopathology among individuals with BED. Behavioral weight control programs may also be effective in decreasing binge eating and do not exacerbate eating disordered behaviors among individuals with BED. In addition, DBT shows promise as an alternative treatment for BED.
Finally, although they were not a focus of this review, a number of pharmacologic approaches are available for treating BED. Some examples include the use of antidepressant medications (e.g., fluoxetine, sertraline), anticonvulsants (i.e., topiramate), and medications designed to promote weight loss.
The choice of treatment for an individual with BED should be guided by a careful review of the benefits and disadvantages of each approach and consideration of the availability of trained clinicians. Future research on essential elements of the psychological approaches, combinations of pharmacologic and psychological treatment, and the best ways in which to match patients to specific treatment approaches are all necessary to improve our understanding of the effective management of BED.
- Linehan MM. Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press, 1993.
- Linehan MM. Skills Training Manual for Treating Borderline Personality Disorder. New York: The Guilford Press, 1993.
- Telch CF, Agras WS, and Linehan MM. Dialectical behavior therapy for binge eating disorder. J Consult Clin Psychol 2001; 69:1061.