What is the first line treatment for binge eating disorder?

First-Line Treatment for Binge Eating Disorder

The first-line treatment for binge eating disorder (BED) is eating disorder-focused cognitive-behavioral therapy (CBT). 1

Treatment Algorithm

1. Initial Treatment: Cognitive-Behavioral Therapy

   • Eating disorder-focused CBT should be the primary intervention
   • CBT specifically addresses:
     • Normalizing eating patterns
     • Reducing binge eating episodes
     • Addressing psychological aspects of the disorder
     • Improving body image disturbance

2. Pharmacological Options (as adjunct or alternative)

   • Fluoxetine (60mg daily) can be prescribed if there is minimal or no response to psychotherapy alone by 6 weeks 1, 2
   • Lisdexamfetamine is FDA-approved specifically for BED 3, 4
   • Duloxetine may be beneficial for BED with comorbid mood symptoms 3

3. Alternative Psychological Treatments

   • Interpersonal Psychotherapy (IPT) is an effective alternative, particularly for patients with:
     • Low self-esteem
     • High eating disorder psychopathology 3, 5
   • Guided self-help based on CBT (CBTgsh) can be effective for many patients 5, 6

Evidence Strength and Considerations

The American Psychiatric Association (APA) recommends eating disorder-focused CBT as the primary treatment for BED with a 1C recommendation level 1. This recommendation is supported by multiple randomized controlled trials showing CBT's effectiveness in reducing binge eating episodes and improving eating disorder psychopathology 5, 4.

For patients who don't respond adequately to CBT alone, pharmacotherapy can be added. Fluoxetine at 60mg daily has shown efficacy for treating binge eating behaviors 2. Lisdexamfetamine is the only FDA-approved medication specifically for BED 4.

Long-term studies have demonstrated that both IPT and CBTgsh are more effective than behavioral weight loss treatment in maintaining remission from binge eating over a 2-year follow-up period 5.

Special Considerations

• Treatment Goals: Focus primarily on reducing binge eating episodes and improving eating disorder psychopathology rather than solely on weight loss 3
• Comorbidities: BED frequently co-occurs with mood disorders, anxiety disorders, and substance use disorders, which may influence treatment selection 3, 7
• Monitoring: Regular assessment of:
  • Binge frequency
  • Psychological symptoms (depression, anxiety)
  • Weight (as a secondary outcome)
  • Medication side effects 3

Technology-Based Interventions

Internet-based guided self-help programs have shown promise for BED treatment 1, 6. These approaches may be particularly valuable for:

• Patients with barriers to accessing in-person therapy
• As an initial intervention while waiting for specialized treatment
• As a supplement to other treatments

Common Pitfalls to Avoid

1. Focusing solely on weight loss rather than addressing the core eating disorder psychopathology
2. Failing to screen for comorbid conditions that may affect treatment response
3. Not providing adequate follow-up - BED is often chronic and requires ongoing monitoring
4. Prescribing stimulant medications (like lisdexamfetamine) to patients with uncontrolled hypertension, cardiovascular disease, or history of substance abuse 3

By following this evidence-based approach, clinicians can effectively treat binge eating disorder with the goal of reducing binge eating episodes, improving psychological well-being, and enhancing overall quality of life.