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Cognitive Behavioral Therapy Should Be First-Line Treatment Approach for Binge Eating

  • Authors: News Author: Janis C. Kelly
    CME Author: Charles P. Vega, MD
  • CME Released: 1/20/2010
  • Valid for credit through: 1/20/2011
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Target Audience and Goal Statement

This article is intended for primary care clinicians, psychiatrists, and other specialists who care for patients with binge eating disorder.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe characteristics of binge eating disorder.
  2. Compare psychological treatments of binge eating disorder.


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  • Janis Kelly

    Janis Kelly is a freelance writer for Medscape. She has been a medical journalist since 1976, with extensive work in rheumatology, immunology, neurology, sports medicine, AIDS and infectious diseases, oncology, and respiratory medicine.


    Disclosure: Janis Kelly has disclosed no relevant financial information.


  • Brande Nicole Martin

    CME Clinical Editor, Medscape, LLC


    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Charles P. Vega, MD

    Associate Professor and Residency Director, Department of Family Medicine, University of California-Irvine, Irvine California


    Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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Cognitive Behavioral Therapy Should Be First-Line Treatment Approach for Binge Eating

Authors: News Author: Janis C. Kelly CME Author: Charles P. Vega, MDFaculty and Disclosures

CME Released: 1/20/2010

Valid for credit through: 1/20/2011


January 20, 2010 — The first randomized controlled trial to compare psychological treatments for binge eating disorder shows that, for most patients, guided self-help based on cognitive behavior therapy (CBTgsh) should be considered first-line treatment.

The study, led by G. Terence Wilson, PhD, Rutgers, The State University of New Jersey, Piscataway, compared 2-year results with CBTgsh, behavioral weight loss treatment (BWL), and interpersonal psychotherapy (IPT) in 205 patients with a body mass index (BMI) between 27 and 45 who met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for binge eating disorder. The main outcome variable was binge eating, assessed by the Eating Disorder Examination (EDE) semistructured interview.

Study coauthor W. Stewart Agras, MD, Stanford University School of Medicine, California, told Medscape Psychiatry that from the clinician's viewpoint, it would be reasonable to conclude that for most binge eating disorder patients, CBTgsh should be first-line treatment.

"The fact that a guided self-help treatment was as effective as IPT at the end of treatment and at 2-year follow-up [was a surprise]," Dr. Agras said. "This simpler therapy could be more easily disseminated than IPT."

The study is published in the January issue of Archives of General Psychiatry.

Significant Reduction

Subjects were randomized to 20 sessions of BWL, 20 sessions of IPT, or 10 sessions of CBTghs. BWL was delivered by master's-level therapists in clinical psychology or nutrition. IPT was delivered by doctoral-level PhD or PsyD therapists.

CBTghs was delivered by first- or second-year graduate students with no experience in CBTgsh or in treating binge eating disorder, who had been trained in a 3-hour workshop using manualized treatment based on Christopher G. Fairburn's book, Overcoming Binge Eating.

Participants' self-esteem was assessed using the Rosenberg Self Esteem Scale and binge eating severity using the EDE.

At 2-year follow-up, binge eating had decreased significantly in the IPT and CBTgsh groups, but not in the BWL group. Patients with low self-esteem and those with both low self-esteem and more severe binge eating did particularly poorly with BWL treatment.

IPT subjects with low self-esteem did as well as those with high self-esteem, regardless of binge eating severity. CBTgsh was equally effective in those with less severe binge eating regardless of whether they had high or low self-esteem.

Convincing Data

"From a clinical viewpoint, we have not established a cut point for self-esteem/more severe eating disorder. One way to proceed would be to begin with the cheapest treatment CBTgsh, and if that did not work, use IPT or alternatively go straight to IPT for more severe binge eating disorder," said Dr. Agras.

"I don't think that it tells us much about binge eating disorder, but the fact that a cheaper treatment is as good as a full-blown treatment is of great interest," Dr. Agras said. "For binge eating disorder weight loss is associated with less binge eating, but it appears that weight gain after the loss is associated with relapse."

Commenting on the findings, Albert J. Stunkard, MD, professor of psychiatry in the Weight and Eating Disorders Program at the University of Pennsylvania in Philadelphia, said the data are convincing.

"The authors' conclusion that guided self-help based on cognitive behavior therapy should be the first line of treatment for most patients with binge eating disorder is a reasonable conclusion from their data, and I do not know of any conflicting findings."

The study was supported by the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Arch Gen Psychiatry. 2010;67:94-101.

Clinical Context

Binge eating disorder is defined by frequent, persistent binge eating episodes that are accompanied by feelings of loss of control. Patients with this disorder lack regular compensatory behaviors for binge eating. Binge eating disorder is associated with significant psychological comorbidity as well as general health risks. Binge eating is also associated with higher risks for overweight and obesity.

Previous research has demonstrated that multiple psychological treatments may be effective to treat binge eating disorder. The current study compares these different treatments.

Study Highlights

  • Study participants met standard diagnostic criteria for binge eating disorder and were recruited from 2 university treatment centers in the United States. All participants were at least 18 years old and had a BMI between 27 and 45 kg/m2. Patients with significant other medical conditions were excluded from study participation.
  • Participants were randomized to receive IPT, BWL, or CBTgsh. Treatments were completed for 24 weeks, and follow-up of study participants continued for 2 years.
  • IPT focused on discovery of the interpersonal context for binge eating disorder for 4 sessions, planning for change for 4 sessions, and review of each patient's progress for 3 sessions. IPT was delivered by doctoral-level psychologists.
  • BWL consisted of diet and exercise instruction in 16 weekly sessions, followed by 4 more sessions at 2-week intervals.
  • CBT was delivered for 10 sessions and focused on self-control and self-monitoring strategies as well as problem-solving and relapse management. CBTgsh was delivered by inexperienced first-year psychology graduate students.
  • The main study outcome was remission from binge eating disorder at 2 years, which was measured by the Eating Disorders Examination, a semi-structured interview. Participants also completed evaluations of mood, self-esteem, and social adjustment.
  • 205 individuals underwent randomization. The average age of participants was in the late 40s, and more than 80% of the study cohort consisted of women.
  • Study subjects expected IPT to be more successful than CBT at the end of sessions 1 and 4.
  • Study dropout rates were 7%, 28%, and 30% in the IPT, BWL, and CBT groups, respectively. Participants with a negative affect at baseline were more likely to drop out of BWL, whereas patients with a more positive affect were more likely to complete BWL than CBT.
  • There was no difference between randomization groups in remission from binge eating disorder at the end of active treatment at 24 weeks. BWL was associated with more weight loss vs IPT and CBT at 24 weeks.
  • At 2 years, both IPT and CBT were more effective than BWL in remission from binge eating, and BWL was no longer superior to the other treatments regarding weight loss.
  • Negative affect at baseline was associated with lower rates of remission from binge eating disorder at 24 weeks but not at 2 years.
  • Patients with frequent binge eating at baseline responded best to IPT, and lower self-esteem reduced the efficacy of BWL more than IPT.

Clinical Implications

  • Binge eating disorder is defined by frequent, persistent binge eating episodes that are accompanied by feelings of loss of control. Patients with this disorder lack regular compensatory behaviors for binge eating. Binge eating disorder is associated with significant psychological comorbidity as well as higher risks for overweight and obesity.
  • In the current study, IPT and CBT were superior to BWL in eliminating binge eating at 2 years.

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