Treatment of binge eating disorder.Psychiatr Clin North Am. 2011 Dec; 34(4):773-83.PC
The two specialty psychological therapies of CBT and IPT remain the treatments of choice for the full range of BED patients, particularly those with high levels of specific eating disorder psychopathology such as overvaluation of body shape and weight. They produce the greatest degree of remission from binge eating as well as improvement in specific eating disorder psychopathology and associated general psychopathology such as depression. The CBT protocol evaluated in the research summarized above was the original manual from Fairburn and colleagues. Fairburn has subsequently developed a more elaborate and sophisticated form of treatment, namely, enhanced CBT (CBT-E) for eating disorders. Initial research suggests that CBT-E may be more effective than the earlier version with bulimia nervosa and Eating Disorder Not Otherwise Specified patients. CBT-E has yet to be evaluated for the treatment of BED, although it would currently be the recommended form of CBT. Of relevance in this regard is that the so-called broad form of the new protocol includes 3 optional treatment modules that could be used to address more complex psychopathology in BED patients. One of the modules targeted at interpersonal difficulties is IPT, as described earlier in this chapter. Thus, the broader protocol could represent a combination of the two currently most effective therapies for BED. Whether this combined treatment proves more effective than either of the components alone, particularly for a subset of BED patients with more complex psychopathology, remains to be tested. CBT-E also includes a module designed to address what Fairburn terms “mood intolerance” (problems in coping with negative affect) that can trigger binge eating and purging. The content and strategies of this mood intolerance module overlap with the emotional regulation and distress tolerance skills training of Linehan's dialectical behavior therapy (DBT). Two randomized controlled trials have tested the efficacy of an adaptation of DBT for the treatment of BED (DBT-BED) featuring mindfulness, emotion regulation, and distress tolerance training. A small study by Telch and colleagues found that modified DBT-BED was more effective than a wait list control in eliminating binge eating. A second study showed that DBT-BED resulted in a significantly greater remission rate from binge eating at posttreatment than a group comparison treatment designed to control for nonspecific therapeutic factors such as treatment alliance and expectations.50 This difference between the two treatments disappeared over a 12-month follow-up, indicating the absence of DBT-BED-specific influences on long-term outcomes. Both CBT and IPT have been shown to be more effective in eliminating binge eating than BWL in controlled, comparative clinical trials. Nonetheless, BWL has been effective in reducing binge eating and associated eating problems in BED patients in some studies and might be suitable for treatment of BED patients without high levels of specific eating disorder psychopathology. A finding worthy of future research is the apparent predictive value of early treatment response to BWL, indicating when BWL is likely to prove effective or not. No evidence supports the concern that BWL's emphasis on moderate caloric restriction either triggers or exacerbates binge eating in individuals with BED. Initially, CBTgsh was recommended as a feasible first-line treatment that might be sufficient treatment for a limited subset of patients in a stepped care approach. More recent research, however, has shown that CBTgsh seems to be as effective as a specialty therapy, such as IPT, with a majority of BED patients. The subset of patients that did not respond well to CBTgsh in this research were those with a high level of specific eating disorder psychopathology, as noted. A plausible explanation for this moderator effect is that the original Fairburn CBTgsh manual does not include an explicit emphasis on body shape and weight concerns. Subsequent implementation of this treatment has incorporated a module that directly addresses overvaluation of body shape and weight. Future research should determine whether an expanded form of CBTgsh is suitable for the full range of patients with BED. CBTgsh is recommended as a treatment for BED on two other counts. First, its brief and focused nature makes it cost effective. Second, its structured format makes it more readily disseminable than other longer, multicomponent psychological therapies. It can be implemented by a wider range of treatment providers than more technically complex, time-consuming, and clinical expertise-demanding specialty therapies such as CBT-E and IPT. The latter evidence-based therapies are rarely available to patients with BED in routine clinical care settings. Nevertheless, it must be noted that much of the research on CBTgsh to date has been conducted in an eating disorder specialty clinic setting. The degree to which the treatment can be adapted to a range of clinical service settings remains to be determined. In addition, little is known about the specific provider qualifications and level of expertise required to implement CBTgsh successfully. Despite its brief and focal nature, specific provider skills regarding what and what not to address in treatment are required. Currently available pharmacologic treatments cannot be recommended for treatment of BED. Aside from the inconsistent results of existing studies, the striking absence of controlled long-term evaluation of such treatment argues against its use.As summarized, the evidence-based treatments of CBT, IPT, and CBTgsh result in significant improvement and large treatment effects on multiple outcome measures aside from binge eating in overweight and obese patients. These include specific eating disorder psychopathology (eg, overvaluation of body shape and weight), general psychopathology (eg, depression), and psychosocial functioning. Moreover, these changes are typically well-maintained over 1 to 2 years of follow-up. The exception to this profile of improvement remains weight loss and its maintenance over time. These specialty psychological treatments do not produce weight loss, although successfully eliminating binge eating might protect against future weight gain. BWL consistently produces short-term weight loss, the extent of which has varied across different studies. Long-term weight loss has yet to be demonstrated, however. In this regard, the findings with obese patients with BED are not different than those on the treatment of obesity in general, in which there is little robust evidence of enduring weight loss effects of BWL.