Evidence-Based Reviews

Beating obesity: Help patients control binge eating disorder and night eating syndrome

Current Psychiatry. 2006 June;5(6):17-28

References

1. Taraldsen KW, Eriksen L, Gotestam KG. Prevalence of eating disorders among Norwegian women and men in a psychiatric outpatient unit. Int J Eat Disord 1996;20:185-90.

2. Lundgren JD, Allison KC, Crow S, et al. Prevalence of the night-eating syndrome in a psychiatric population. Am J Psychiatry 2006;163:156-8.

3. Streigel-Moore RH, Franko DL. Epidemiology of binge eating disorder. Int J Eating Disord 2003;34:S19-S29.

4. Striegel-Moore RH, Wilfley DE, Pike KM, et al. Recurrent binge eating in black American women. Arch Fam Med 2000;9:83-7.

5. Marshall HM, Allison KC, O’Reardon JP, et al. Night eating syndrome among nonobese persons. Int J Eat Disord 2004;35:217-22.

6. Spitzer RL, Yanovski S, Wadden T, et al. Binge eating disorder: its further validation in a multisite study. Int J Eat Disord 1993;13:137-53.

7. Fairburn CG, Cooper Z, Doll HA, et al. The natural course of bulimia nervosa and binge eating disorder in young women. Arch Gen Psychiatry 2000;37:659-65.

8. Fontaine KR, Redden DT, Wang C, et al. Years of life lost due to obesity. JAMA 2003;289:187-93.

9. Rieger E, Wilfley DE, Stein RI, et al. A comparison of quality of life in obese individuals with and without binge eating disorder. Int J Eat Disord 2005;37:234-40.

10. Yanovski SZ, Nelson JE, Dubbert BK, Spitzer RL. Association of binge eating disorder and psychiatric co-morbidity in obese subjects. Am J Psychiatry 1993;150:1472-9.

11. Gluck ME, Geliebter A, Satov T. Night eating syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less weight loss in obese outpatients. Obes Res 2001;9:264-7.

12. Stunkard AJ, Allison KC. Two forms of disordered eating in obesity: Binge eating and night eating. Int J Obes Relat Metab Disord 2003;7:1-12.

13. O’Reardon JP, Peshek A, Allison K. Night eating syndrome: Diagnosis, epidemiology, and management. CNS Drugs 2005;19:997-1008.

14. Agras WS, Teich CF, Arnow B, et al. One-year follow-up of cognitive-behavioral therapy for obese individuals with binge-eating disorder. J Consult Clin Psychol 1997;65:343-7.

15. Cloak NL, Powers PS. Are undiagnosed eating disorders keeping your patients sick? Current Psychiatry 2005;4(12):65-75.

16. Kushner RF, Roth JL. Medical evaluation of the obese individual. Psychiatr Clin North Am 2005;28:89-103.

17. Wonderlich SA, de Zwaan M, Mitchell JE, et al. Psychological and dietary treatments of binge eating disorder: conceptual implications. Int J Eat Disord 2003;34:S58-S73.

18. Grilo CM, Masheb RM. A randomized controlled comparison of guided self-help cognitive behavioral therapy and behavioral weight loss for binge-eating disorder. Behav Res Ther 2005;43:1509-25.

19. Wilfley DE, Welch RR, Stein RI, et al. A randomized comparison of group cognitive-behavioral therapy and group interpersonal therapy for the treatment of overweight individuals with binge eating disorder. Arch Gen Psychiatry 2002;59:713-21.

20. Telch CF, Agras WS, Linehan MM. Dialectical behavior therapy for binge eating disorder. J Consult Clin Psychol 2001;69:1061-5.

21. Pendleton VR, Goodrick CK, Poston WS, et al. Exercise augments the effects of cognitive-behavioral therapy in the treatment of binge eating. Int J Eat Disord 2002;31:172-84.

22. Agras WS. Pharmacotherapy of bulimia nervosa and binge eating disorder: longer-term outcomes. Psychopharmacol Bull 1997;33:433-6.

23. Clinical guidelines on the identification evaluation and treatment of obesity in adults Executive summary, 1998. Bethesda, MD: National Heart, Lung, and Blood Institute. Available at: http://www.nhlbi.nih.gov/guidelines/obesity. Accessed April 18, 2006.

24. Tsai AG, Wadden TA, Womble LG, Byrne KJ. Commercial and self-help programs for weight control. Psychiatr Clin North Am 2005;28:171-92.

25. Wadden TA, Foster GD, Sarwer DB, et al. Dieting and the development of eating disorders in obese women: Results of a randomized controlled trial. Am J Clin Nutr 2004;80:560-8.

26. Pawlow LA, O’Neil PM, Malcolm RJ. Night eating syndrome: Effects of brief relaxation training on stress, mood, hunger, and eating patterns. Int J Obes Relat Metab Disord 2003;27:970-8.

27. O’Reardon JP, Stunkard AJ, Allison KC. A clinical trial of sertraline in the treatment of night eating syndrome. Int J Eat Disord 2004;35:16-26.

28. Winkelman JW. Treatment of nocturnal eating syndrome and sleep-related eating disorder with topiramate. Sleep Med 2003;4(3):243-6.

29. Friedman S, Even C, Dardennes R, Guelfi JD. Light therapy, obesity, and night-eating syndrome. Am J Psychiatry 2002;159:875-6.

Obtain a history of the patient’s eating disorder and weight, calculate BMI, and assess for psychiatric comorbidity.¹⁵ Make sure blood pressure and fasting lipids and glucose are monitored in patients who are overweight (BMI ≥27) or obese (BMI ≥30).¹⁶ Question patients with night eating about sleep disorder symptoms and use of hypnotics—especially short-acting benzodiazepines and zolpidem, which have been associated with sleep-related eating disorder.

Box 3

Differentiating characteristics of four eating disorders

Disorder	Bulimia nervosa	Binge eating disorder	Night-eating syndrome	Sleep-related eating disorder
Morning anorexia	No	No	Yes	Yes
Evening hyperphagia	No	No	Yes	No
Eating pattern	Binges	Binges	Snacks	Snacks, unusual items
Compensatory behavior	Yes	No	No	No
Awareness of eating	Yes	Yes	Yes	No
Polysomnography	Normal	Normal	Low sleep efficiency	Sleep disorder
Treatment	CBT, SSRIs	CBT, SSRIs	Sertraline, relaxation	Treat sleep disorder; dopamine agonists
CBT: cognitive-behavioral therapy
SSRIs: selective serotonin reuptake inhibitors

Controlling binge eating

Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), dialectical behavior therapy (DBT), and medications have treated BED effectively in randomized, controlled trials:

The psychotherapies are equally effective in decreasing bingeing but have little impact on weight.
Medications are less effective in reducing bingeing but are associated with modest weight loss.

Psychotherapy. The most-studied intervention for BED is CBT, which leads to remission (abstinence from bingeing ≥28 days) in 50% to 60% of patients.¹⁷ CBT techniques for BED adapt readily to self-help programs (Box 4).

In one study patients worked with a self-help manual while meeting biweekly with therapists for 15 to 20 minutes in individual sessions. They were randomly assigned to CBT, behavioral weight loss, or control (self-monitoring only) groups. At 12 weeks, remission rates were:

46% with CBT
18.4% with behavioral weight loss
13.3% for controls.

Patients in the intervention groups lost some weight, but no group showed significant changes in BMI.¹⁸ The manual used in this study is available in bookstores and online (see Related resources for patients and clinicians).

Although somewhat less effective than therapist-led CBT, guided self-help is easy to implement in a general psychiatric practice.

A randomized, controlled trial compared CBT with IPT in 20 weekly group sessions. Posttreatment remission rates were equivalent—79% for CBT versus 73% for IPT—and weight in both groups was essentially unchanged.¹⁹

Abstinence rates after group DBT were 89% in a randomized, controlled trial of 44 women with BED. Binge eating improved significantly more in those assigned to DBT, compared with wait-listed controls. Differences in weight and mood were not significant, and abstinence rates slipped to 56% 6 months after DBT ended.²⁰

Box 4

CBT principles for treating binge-eating disorder

Self-monitor

Keep detailed records of all dietary intake
Look for patterns in timing, type, and amount of food eaten
Note antecedents and consequences of binges

Eat regularly

Have 3 planned meals and 2 snacks per day
Reduce cues to eat at other times

Substitute other behaviors for bingeing

List pleasant alternate activities
Recognize urges to binge
Choose a substitute activity
Review efficacy of substitute behaviors in preventing binges

Revise erroneous thinking patterns

Reduce unrealistic expectations (especially about weight loss)
Minimize self-criticism in response to lapses
Change polarized thinking (“I’ve blown my diet; I may as well binge.”)

Limit vulnerabilities to relapse

Reduce concerns about weight and shape
Address problems with self-esteem, depression, or anxiety
Maintain realistic expectations

Source: Fairburn CG. Overcoming binge eating. New York: Guilford Press; 1995.

Medications evaluated for BED in randomized, placebo-controlled trials include selective serotonin reuptake inhibitors (SSRIs) and a tricyclic, obesity management agents (sibutramine and orlistat), and topiramate (Box 5). Binge eating remission rates were highest with antidepressants, and patients lost the most weight with orlistat and sibutramine.

Box 5

Randomized, controlled trials of medications for binge-eating disorder (BED)

Medication	Dosage (mg/d)	Duration (weeks)	N	BED remission (%)		Weight loss (kg)*
Medication	Dosage (mg/d)	Duration (weeks)	N	Drug	Placebo	Weight loss (kg)*
Citalopram	20 to 60	6	38	47	21	2.3
Desipramine	100 to 300	8	23	60	15	2.3
Fluoxetine	20 to 80	6	60	45	21	4.6
Fluvoxamine	50 to 300	9	85	38	26	1.7
Orlistat	120 tid	24	89	23	29	5.1
Sertraline	50 to 200	6	34	47	14	4.4
Sibutramine^†	15	12	60	Not reported		8.8
Topiramate	50 to 600	14	58	64	30	4.8
* Difference between weight lost with drug and weight lost with placebo
† Sibutramine is a controlled substance (schedule IV) and is recommended only for obese patients with BMI ≥30 (≥27 if cardiac risk factors are present). Do not use with monoamine oxidase inhibitors or serotonergic agents, and monitor blood pressure.
Source: Carter WP, Hudson JI, Lalonde JK, et al. Pharmacologic treatment of binge eating disorder. Int J Eat Disord 2003;34:S74-S88

Combining CBT with medications or exercise has also been evaluated for BED in randomized, controlled trials:²¹

Group CBT and fluoxetine, 60 mg/d, were compared with placebo in 108 patients. After 16 weeks, intent-to-treat remission rates were 22% (fluoxetine), 26% (placebo), 50% (CBT + fluoxetine), and 61% (CBT + placebo). Weight loss did not differ significantly among treatments but was associated with binge eating remission.
Guided self-help CBT combined with orlistat, 120 mg tid, or placebo were compared in 50 patients. After 12 weeks, intent-to-treat remission rates were significantly higher with orlistat (64% versus 36%) but not 3 months later (52% each). Weight loss of ≥5% was seen in 36% of those taking orlistat and in 8% taking placebo.
Binge eating abstinence doubled when exercise (45 minutes. 3 times/week) was added to CBT; weight loss and mood also improved.