What is the treatment approach for Binge Eating Disorder (BED) as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V)?

Treatment Approach for Binge Eating Disorder (DSM-5)

Cognitive-behavioral therapy (CBT) is the first-line treatment for Binge Eating Disorder, with lisdexamfetamine as the only FDA-approved medication for moderate-to-severe cases. 1, 2

Initial Treatment Strategy

Psychotherapy as Primary Intervention

• Start with eating disorder-focused CBT delivered in either individual or group format, as this represents the gold-standard psychological treatment with the strongest evidence base 1, 3
• Interpersonal therapy (IPT) serves as an equally effective alternative to CBT and should be offered when CBT is unavailable or not preferred by the patient 1, 3
• Dialectical behavior therapy (DBT) represents a third-line psychotherapy option with emerging evidence for efficacy 4, 3
• Behavioral weight loss (BWL) interventions demonstrate comparable effectiveness to CBT for reducing binge eating and eating-disorder psychopathology, with the added benefit of producing modest weight loss 3

When to Add Pharmacotherapy

• Add lisdexamfetamine (50-70 mg/day) when psychotherapy alone produces inadequate response or for patients with moderate-to-severe BED who require more intensive intervention 1, 2
• Lisdexamfetamine is the only FDA-approved medication specifically for BED, demonstrating statistically significant reductions in binge days per week (1.35-1.66 fewer binge days compared to placebo at 12 weeks) 2
• Consider selective serotonin reuptake inhibitors (SSRIs) as alternative pharmacological agents when lisdexamfetamine is contraindicated or not tolerated, though evidence is more limited 4, 1

Treatment Implementation Algorithm

Step 1: Comprehensive Assessment

• Conduct psychiatric evaluation quantifying eating behaviors and identifying co-occurring psychiatric disorders (present in 79% of BED patients) 1, 5
• Perform physical examination documenting vital signs, height, weight, and BMI 1
• Order laboratory assessment including complete blood count and comprehensive metabolic panel 1

Step 2: Initiate First-Line Treatment

• Begin with CBT or IPT as monotherapy for 12 weeks 1, 3
• These psychological treatments work quickly for many patients and produce durable benefits after treatment completion 3

Step 3: Assess Response and Adjust

• If inadequate response to psychotherapy alone after 12 weeks, add lisdexamfetamine starting at 30 mg/day, titrating to 50 mg/day after one week, with potential increase to 70 mg/day as tolerated 2
• Combining medications with psychological treatments does not enhance outcomes compared to psychotherapy alone, but is superior to pharmacotherapy alone 3

Critical Treatment Considerations

Multidisciplinary Team Approach

• Assemble a coordinated team incorporating medical, psychiatric, psychological, and nutritional expertise 1, 6
• Include a physician, mental health provider, and dietitian as core team members 4

Common Pitfalls to Avoid

• Do not make weight loss the primary treatment focus—instead prioritize normalizing eating patterns and addressing underlying psychological factors 1
• Do not assume routine antidepressants for comorbid anxiety or depression will ameliorate BED symptoms; these require specific BED-focused interventions 5
• Avoid combining multiple interventions simultaneously at treatment initiation, as this does not add significant advantages over sequential treatment approaches 7

Monitoring and Follow-Up

• Track binge eating behaviors, weight, and psychological symptoms regularly throughout treatment 1
• Plan for longer-term follow-up, as maintenance of treatment gains requires ongoing monitoring 7

Special Populations

• For patients with significant psychiatric comorbidities (anxiety, depression, obsessive-compulsive disorder), address these conditions concurrently as they may impair treatment participation 6
• Consider more intensive interventions or hospitalization for patients who cannot control binge eating behaviors despite outpatient treatment 6

Emerging Treatment Considerations

• Lower-cost scalable interventions like guided self-help CBT (CBTgsh) demonstrate efficacy and have potential for broader implementation when specialist care is unavailable 3
• Mindfulness training represents an emerging therapeutic approach with preliminary supporting evidence 4
• Neurobiological targets including reward processing, inhibitory control, and emotion regulation represent promising areas for future treatment development 8, 9