What is the first line treatment for patients with sensory seeking compulsive eating disorder who have gained a significant amount of weight in a short time?

First-Line Treatment for Sensory-Seeking Compulsive Overeating with Rapid Weight Gain

Initiate eating disorder-focused cognitive-behavioral therapy (CBT) immediately as first-line treatment, and if there is minimal or no response by 6 weeks, add either lisdexamfetamine or an antidepressant medication. 1

Understanding the Clinical Picture

The presentation described—sensory-seeking compulsive overeating with rapid weight gain—most closely aligns with binge-eating disorder (BED), which is the most common eating disorder with a lifetime prevalence of 0.85% in US adults 2. The "sensory-seeking" component suggests obsessive thoughts and compulsive behaviors regarding food, which are core drivers of binge eating 2.

Initial Assessment Requirements

Before initiating treatment, complete the following mandatory evaluations 1, 3:

• Weigh the patient and calculate BMI
• Quantify eating behaviors: frequency and intensity of binge episodes, time spent preoccupied with food
• Vital signs: temperature, resting heart rate, blood pressure, orthostatic pulse and blood pressure
• Laboratory work: complete blood count and comprehensive metabolic panel (electrolytes, liver enzymes, renal function)
• Screen for psychiatric comorbidities: anxiety disorders, mood disorders, impulse control disorders, and substance use disorders occur in most adults with BED 2

Treatment Algorithm

Step 1: Eating Disorder-Focused Psychotherapy (Weeks 0-6)

Start with eating disorder-focused CBT as the primary intervention 1. This therapy should address:

• Normalizing eating patterns and reducing binge frequency
• Challenging dysfunctional thinking about food, weight, and body shape
• Developing non-food coping skills for emotional regulation 4, 5

Alternative psychotherapy options with equivalent efficacy 4, 6:

• Interpersonal psychotherapy (IPT) in individual or group format 1
• CBT guided self-help (CBTgsh) for patients without high levels of body shape/weight overvaluation 4

Step 2: Add Pharmacotherapy if Inadequate Response by Week 6

If binge eating persists or shows minimal improvement by 6 weeks, add medication 1, 7:

Primary pharmacologic option:

• Lisdexamfetamine: The only FDA-approved medication specifically for moderate to severe BED 7, 2
• Addresses core drivers: obsessive thoughts and compulsive behaviors regarding food
• Produces marked decreases in binge eating behaviors plus weight loss 2

Alternative pharmacologic option:

• Antidepressant medication (particularly SSRIs) if lisdexamfetamine is contraindicated or not tolerated 1, 7

Critical Distinctions from Other Eating Disorders

This treatment approach differs significantly from bulimia nervosa and anorexia nervosa 1, 3:

• Bulimia nervosa: Fluoxetine 60 mg daily is first-line pharmacotherapy (not 20 mg standard antidepressant dosing) 3
• Anorexia nervosa: No medications are approved; psychotherapy with nutritional rehabilitation is the cornerstone 3

What NOT to Do

Avoid behavioral weight loss (BWL) therapy as first-line treatment for patients with high levels of eating disorder psychopathology (overvaluation of body shape/weight) 4, 6. While BWL can reduce binge eating in some patients, it:

• Is less effective than CBT or IPT for eliminating binge eating 4
• Produces only short-term weight loss without long-term maintenance 4, 8
• Is suitable only for BED patients without significant eating disorder psychopathology 4

Monitoring Treatment Response

Assess response every 6 weeks 3:

• Quantify binge eating frequency weekly
• Monitor weight and BMI
• Reassess vital signs and metabolic parameters
• Screen for suicidality regularly: eating disorders carry among the highest mortality rates of psychiatric conditions 7

Multidisciplinary Coordination

All eating disorder treatment requires coordination among medical, psychiatric, psychological, and nutritional expertise 1, 3. Document a comprehensive, culturally appropriate, person-centered treatment plan 1.

Alternative Delivery Methods

For patients with barriers to in-person care (shame, stigma, geographic distance), guided computer-based interventions and videoconferencing show promise, though adherence can be challenging with only 57% completing full treatment 3, 9.

Expected Outcomes

CBT and IPT produce 4, 6:

• Large treatment effects on binge eating elimination
• Significant improvement in eating disorder psychopathology and depression
• Well-maintained changes over 1-2 years follow-up
• Protection against future weight gain when binge eating is eliminated
• Minimal to no weight loss from psychotherapy alone (weight loss requires adding lisdexamfetamine or BWL)