Binge Eating Disorder (BED)
Recurrent binge eating without compensatory behaviors; most common eating disorder.
Also known as: BED, binge eating disorder, compulsive overeating
Overview
Recurrent episodes of binge eating without recurrent inappropriate compensatory behaviors, occurring on average >=1/week for >=3 months, with marked distress, and associated features such as eating rapidly, until uncomfortably full, when not hungry, alone due to embarrassment, or with subsequent disgust/depression/guilt.
Epidemiology
Lifetime prevalence ~1-3% (most common eating disorder in US adults). Female-to-male ratio ~1.5:1. Strongly associated with obesity though not all patients are obese.
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Risk factors
- Family history of eating disorders, obesity, mood disorders
- Childhood obesity, dieting history
- Trauma, adverse childhood experiences
- Mood, anxiety, ADHD, substance use comorbidity
- Female sex
Pathophysiology
Dysregulated reward processing with altered dopaminergic signaling and impaired prefrontal inhibitory control. Negative affect and dietary restraint serve as binge precipitants.
Clinical presentation
Symptoms
- Episodes of eating a large amount of food in <2 hours with loss of control
- Associated features (>=3): rapid eating, eating until uncomfortably full, eating when not hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty afterward
- Marked distress regarding binge eating
- No regular compensatory behaviors
Signs / physical exam
- Often obesity-related findings: HTN, dyslipidemia, type 2 diabetes, OSA
- No specific physical signs unique to BED
Differential diagnosis
- Bulimia nervosa — Binge + compensatory behaviors
- MDD with overeating — Hyperphagia during depressive episodes without loss-of-control quality
- Night eating syndrome — Consumption of >=25% of daily intake after dinner or nocturnal awakenings to eat
- Hypothalamic/genetic obesity syndromes — Prader-Willi, leptin deficiency — early onset, hyperphagia without loss of control concept
Diagnostic workup
Diagnostic criteria
DSM-5-TR: (A) Recurrent binge eating episodes; (B) Associated with >=3 of: rapid eating, eating until uncomfortably full, eating when not hungry, eating alone from embarrassment, feeling guilty/disgusted; (C) Marked distress; (D) Occurs on average >=1/week for >=3 months; (E) Not associated with recurrent compensatory behaviors and not exclusively during anorexia or bulimia. Severity by frequency: mild 1-3, moderate 4-7, severe 8-13, extreme >=14 episodes/week.
Labs
- Metabolic screen: fasting glucose/A1c, lipid panel, LFTs (NAFLD), TSH
- ECG if cardiovascular risk
- Screen for OSA, depression, anxiety
Imaging
- Not routinely indicated for diagnosis
Diagnostic algorithm
| Feature | Bulimia | BED | Anorexia |
|---|---|---|---|
| Weight | Normal/above | Often elevated | Significantly low |
| Binges | Yes | Yes | Sometimes (B/P subtype) |
| Compensatory behaviors | Yes | No | Yes (B/P subtype) or restriction |
| FDA-approved drug | Fluoxetine 60 mg | Lisdexamfetamine | None (olanzapine adjunct) |
Treatment
First-line
- Cognitive behavioral therapy for eating disorders (CBT-ED) — strongest evidence
- Interpersonal therapy (IPT)
- Lisdexamfetamine — FDA-approved for moderate-to-severe BED (30-70 mg/day); reduces binge days
- Self-help CBT for milder disease
Second-line / adjunct
- SSRIs (fluoxetine, sertraline, citalopram) — modest reduction in binge frequency
- Topiramate — reduces binges and supports weight loss; teratogenic, monitor cognitive side effects
- Behavioral weight loss programs as adjunct (do not replace BED-focused treatment)
- Bariatric surgery — outcomes equivalent to non-BED patients with proper presurgical evaluation
Complications
- Obesity and its sequelae: T2DM, HTN, dyslipidemia, CAD, OSA, NAFLD, osteoarthritis
- Depression, anxiety, substance use, suicidality
- Functional impairment, social withdrawal
- Weight cycling
PANCE pearls
- Lisdexamfetamine is the only FDA-approved medication for BED — useful especially when comorbid ADHD; monitor BP, HR, sleep, appetite.
- Treat the eating disorder before pursuing weight-loss interventions — restrictive dieting can worsen binge frequency.
- Roughly half of BED patients have a history of comorbid depression — screen and treat concurrently.
- Many primary care obesity patients have undiagnosed BED — ask about loss of control and binge episodes.
References
- APA 2023 — American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders, 4th ed. (2023)
- NICE NG69 — NICE Guideline 69: Eating disorders
- DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)
- McElroy 2015 — McElroy SL et al. Lisdexamfetamine dimesylate for adults with moderate to severe BED. JAMA Psychiatry 2015
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