Binge Eating Disorder
Binge eating disorder (BED) is a condition characterised in ICD-11 (1) by frequent, recurrent episodes of binge eating (e.g., once weekly or more over a period of three months) with substantial distress about the pattern of binge eating and/or significant functional impairment related to binge eating and its effect (1). Binge eating episodes are distinct from general overeating, typically occurring over a discrete period of time (e.g. 2 hours) and involve difficulty stopping eating (due to a subjective loss of control), a markedly increased volume of food intake and pace of eating, and the loss of restraint regarding the type of food eaten (1). Symptoms of binge eating disorder include eating when not hungry, eating alone or secretly, while emotions such as guilt, shame, depression and/or disgust after bingeing negatively influence the individual’s overall self-evaluation. Considered assessment should include differential diagnosis between BED and Bulimia Nervosa. In BED some form of restriction may be present (e.g. some restriction, vomiting intended to alleviate the physical discomfort from eating large quantity of food) however, in Bulimia Nervosa, binge eating episodes are regularly followed by compensatory behaviours intended to prevent weight gain (e.g., self-induced vomiting, misuse of laxatives or enemas, strenuous exercise) (1). BED is often associated with weight gain over time and obesity, but individuals with BED may also be in a healthy weight range.
There are high rates of co-occurrence of other mental and physical health conditions with anxiety, substance use and other eating disorders being most common (2). There is a substantially increased likelihood of obesity and increased risk of diabetes, hypertension and pain conditions (2). Less than 50% of people with BED receive treatment for their eating disorder although those with co-occurring difficulties may be slightly more likely to access treatment (up to 60%) (2).
Where possible psychological interventions should follow from a thorough multidisciplinary assessment and draw upon psychological formulation to consider co-morbid depression, anxiety and trauma symptoms, metabolic and nutritional factors. This is important given that BED can be associated with poor nutritional status and co-morbid physical conditions such as diabetes, thyroid problems and PCOS (3). Psychological interventions for BED tend not to directly focus on weight loss but on improving a person’s relationship with food regardless of their weight, which is likely to be more beneficial in addressing the eating disorder (3). It is helpful for those who wish to access weight loss treatments (e.g. lifestyle, medication, surgery) to be considered as part of a psychologically-informed MDT, to address and monitor their BED and associated psychological needs during the treatment journey (see also Matrix Obesity guidance).
In the United Kingdom, an estimated 700,000 people have an eating disorder (4). The prevalence of Binge Eating Disorder in Europe is around 1.9% for women and 0.3% for men (4) The prevalence literature largely draws on western cultures (2). Prevalence of BED is estimated to be around 1% in children and young people, increasing to 3% for sub-clinical BED (5). The median age-of-onset of binge eating disorder is estimated to be around late teens to early 20s (2) and emerging research indicates that BED is prevalent amongst women over 60 years old, with mid to late life onset. The prevalence rate of BED in pregnant women has been reported as 5% (3).
This information is for commissioners, managers, trainers, and health care practitioners to consider the evidence base for the delivery of psychological interventions for people with BED. This information is also for people diagnosed with Binge Eating Disorder, their families, and carers. This topic introduction page covers evidence-based psychological interventions used to treat BED in children, young people, and adults, and the psychological practice/settings in which these interventions can be delivered. Given that BED commonly presents with other conditions e.g. depression, anxiety, obesity and chronic pain, the Matrix pages related to these topics may also be relevant.
Exclusions for topic: This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and full guidance on best practice can be found in SIGN Guidance 164: Eating disorders (2022) (3) and NICE (2017) Eating Disorders: Recognition and Treatment (4), SIGN 115: Obesity (6) & SIGN 116 Management of diabetes (7).
A range of psychological interventions have been listed in the treatment table for binge eating disorder. These include interventions with the highest levels of efficacy and the strongest levels of evidence providing support for their first-line recommendation. They also include interventions with lower strength evidence and lower levels of efficacy, that may warrant consideration by clinicians if first-line recommendations are declined or ineffective.
The main outcome considered in evaluating psychological treatment for people with BED is reduction or abstinence from binge eating behaviours. While effective treatment can cause weight loss, this is not the focus of treatment nor the primary intended outcome. The management between appropriate weight management interventions in obesity and effective eating disorder treatment should be considered. See Obesity management guidance for further information.
Children and young people (CYP)
There is limited evidence demonstrating the effectiveness of psychological interventions in children and adolescents with binge eating disorder. SIGN guidance therefore considers it reasonable to extrapolate from evidence from adult populations presenting with BED or other eating disorders, suggesting the consideration of Cognitive Behavioural Therapy (CBT) and Interpersonal Psychotherapy (IPT) or family-based interventions in adolescents with binge eating disorder (3). An RCT focused on CBT in adolescents with binge-eating disorder diagnosis indicated significantly reduced binge-eating episodes and improved binge-eating abstinence at post-treatment, maintained at up to 24 months follow-up (8). IPT(IPT-WG) focusing on loss of control of eating in adolescents (adolescents with binge eating symptoms) has been tested in two trials (9,10) indicating a significant reduction in binge eating over 12 months compared to individuals receiving health education. A pilot trial of family-based IPT with overweight preadolescents at risk of loss of control eating indicated preliminary support for the family based IPT intervention (11).
An alternative to these options, guided self-help interventions, based on CBT principles, and supported by regular brief sessions (e.g. 4-9 20-minute sessions over 20 weeks), can be offered based on the NICE recommendation that this is also a recommended approach for adults (4). Available evidence for self-help interventions in adolescents is sparce, limiting the conclusions that can be drawn at present.
Evidence Overview in Adults
Both SIGN (2022) (3) and NICE (2017) (4) recommend Cognitive Behavioural Therapy (CBT) as a first line intervention for BED. The NICE recommendation is based on a stepped care approach, suggesting that guided self-help based on CBT is offered first, followed by group or individual CBT depending on response to initial treatment, availability of groups or the person’s preferences. SIGN recommends CBT or Interpersonal psychotherapy (IPT) as first-line therapy considerations for adults with binge eating disorder.
The recommendations for CBT are based on a number of meta-analyses involving over 10 RCTs. Both SIGN and NICE guidance consider the evidence for various formats of delivery of CBT treatment. Overall, there are similar outcomes between guided self-help based on CBT principles, group CBT and individual CBT modalities, however, it is noted that study quality is heterogeneous and the quality of evidence for binge-eating outcome was generally very low (3,4,12). NICE provides guidance on the structure and components of effective guided self-help, CBT group interventions and individual therapy. The guided self-help should focus on binge eating, be based on CBT principles and supported by 4-9 sessions which focus on adherence to the programme as drop-out rates can be higher. Group CBT should be: eating disorder focused (CBT-ED), consist of 16 weekly 90 minute groups, focus on psychoeducation, self-monitoring of the eating behaviour and helping the person analyse their problems and goals; include making a daily food intake plan and identifying binge eating cues; include body exposure training and helping the person to identify and change negative beliefs about their body; and help with avoiding relapses and coping with current and future risks and triggers. Individual CBT-ED for adults with binge eating disorder should typically consist of 16 to 20 sessions and develop a biopsychosocial formulation of the person's issues to determine how dietary and emotional factors contribute to their binge eating. It should be explained to the person that although CBT-ED does not aim to alter weight, stopping or reducing binge eating can have this effect in the long term. The person should also be advised not to try to lose weight (for example, by dieting) during treatment as this is likely to trigger binge eating.
Interpersonal psychotherapy has been investigated in two RCTs comparing group IPT with group CBT (13) and Individual IPT with guided self-help CBT (14). The group and individual IPT included up to 20 sessions. The trials had equivalent outcomes in remission and binge eating frequency at end of treatment, 12month follow up, and follow up of up to 4 years (15). These findings were reviewed and summarised in a meta-analysis (16).
Where first-line treatments (cognitive behavioural therapy or interpersonal psychotherapy) are ineffective, unsuitable or unacceptable in adults with binge eating disorder SIGN recommends that other treatment options could be considered, such as dialectical-based therapy, integrative cognitive-affective therapy, brief strategic therapy or schema therapy. These recommendations are based on small trials in specific populations showing limited differences in outcomes between approaches, and it is recommended that further research be undertaken to evaluate efficacy when offering these alternative treatment options (3).
There is promising preliminary evidence from reviews investigating DBT studies, ACT and Mindfulness based interventions. Findings show that while third-wave therapies resulted in symptom improvements and were more efficacious than wait-list controls, third-wave therapies were generally not superior to active psychological comparisons (17,18). The evidence for Compassion Focused Therapy is emerging with a pilot RCT (19) but is not established enough to include as a recommendation at present.
Overview of evidence for older adults
The information available on the treatment of eating disorders in people over the age of 65 years is limited. There is an absence of RCTs and the quality of case reports to date makes it difficult to suggest specific assessment or treatment guidelines for this population (20) and it is suggested that the evidence from adult populations is drawn upon. Clinicians are advised that there are differences in the presentation of psychological problems in later life and to consult Delivering Psychological Therapies and Interventions for Older People for further information on factors relevant to practice.
Overview of Evidence for People with Learning Disabilities
Large scale trials of psychological interventions in general populations tend to exclude people with learning disabilities, therefore there is limited evidence for mental health interventions with this group. For people with learning disabilities and mental health difficulties, NICE (2017) (4) recommend that general guidelines for psychological interventions should be considered, with appropriate adaptations for people with learning disabilities. More information relating to adapting therapy can be found on Delivering effective psychological therapies and interventions to people with Intellectual/Learning Disabilities (content under development).
Overview of Evidence for Harms and Adverse Effects
Like all treatments, psychological therapies have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically (see information relating to safety in the delivery of psychological therapies). Reports of adverse effects are starting to be included in research trials and gathered as part of service provision. Ghadieri (2018) (16) stated that no side effects were reported in trials involving CBT, CBT guided self-help compared to wait list controls as well as trials involving IPT compared to CBT. As yet we do not know if psychological interventions cause more, fewer or similar numbers of adverse effects than no treatment or another treatment, because the evidence in this area is of low quality or absent at present.
|
Recommendation |
Who for? |
List of Interventions |
Type of psychological practice |
Evidence |
Efficacy |
|
| First line | CYP with binge eating disorder or binge eating symptoms | CBT- ED (3,4,8) | Specialist | A | N/a | |
| CYP with binge eating disorder or binge eating symptoms | IPT (3,9,10) (with family involvement (11)) |
Specialist | B | N/a | ||
| Alternative | Children and adolescents with obesity and binge-eating disorder or binge eating symptoms | Guided help, based on CBT components, and supported by regular brief sessions (4) | Enhanced | N/a |
|
Recommendation |
Who for |
List of Interventions |
Type of Psychological Practice |
Level of Evidence |
Efficacy |
| First line recommendation | Adults with binge eating disorder | Cognitive behavioural based therapy delivered as: Guided Self Help based on CBT and supported by regular brief sessions (4,12,15,16,21) Group CBT (3,4,16) Individually delivered CBT (3,4,12,15,22-24) Interpersonal Psychotherapy (3,16) |
Enhanced/ Specialist |
A A |
medium-high N/A |
| Alternative (evidence less established) | Adults with BED or binge eating symptoms, who have had insufficient response to first line intervention or where otherwise indicated | Brief strategic therapy (3) Schema therapy (3) Integrative cognitive-affective therapy (3) Dialectical Behaviour Therapy for Binge Eating Disorder (DBT-BED) (25-27) Acceptance and Commitment Therapy (18) Mindfulness based interventions (18,28,29) |
Enhanced/ Specialist |
A | Low-medium |
With thanks to Laura Szabo for assisting with the references.
Advisory group: Marney Ackroyd, Mairi Albiston, Ishbel Begg, Fiona Calder, Davina Chauhan, Fiona Duffy, Kirsty Gallen, Clare Neilson, Ross Shearer, Alia Ul-Hassan, Joanne Waine.
Technical group: Ishbel Begg, Leeanne Nicklas, Marie Claire Shankland, Joanne Waine
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