Binge-Eating Disorder: Prevalence, Predictors, and Management in the Primary Care Setting

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is generally considered to be the most well-established and empirically supported treatment for BED [118,119]. The cognitive behavioral conceptualization of BED is based on Fairburn, Cooper, and Shafran’s [120] transdiagnostic model of eating disorders (CBT-E), which is an expanded version of the cognitive behavioral model of bulimia nervosa [121]. CBT-E posits that the core pathology in eating disorders is a dysfunctional system in which self-worth is based on eating habits, shape, or weight, and the individual’s ability to control them. Attempts to maintain self-worth by controlling eating, shape, and weight result in extreme and brittle forms of dietary restraint. Inevitable violations of the individual’s dietary rules are then interpreted as lack of self-control, leading to a temporary abandonment of dietary restraint and consequent BE. These dietary slips and corresponding BE often occur in response to acute changes in mood, and BE is thus negatively reinforced by “neutralizing” negative mood states. Lapses in dietary restraint also result in secondary negative self-evaluation, which serves to further exacerbate a cycle of increased dietary restraint to improve self-worth and then inevitable dietary lapses leading to BE. CBT-E expanded upon CBT-BN by postulating 4 processes that maintain ED: severe perfectionism (clinical perfectionism), unconditional and pervasive low self-esteem (core low self-esteem), difficulties coping with intense mood states (mood intolerance), and developmental interpersonal difficulties (interpersonal difficulties). Of note, the CBT-E model explicitly states that individuals may differ in the extent to which they experience the 4 maintaining processes and not every individual will experience all four.

Overall, treatment is focused on normalizing eating patterns (ie, not weight loss), cognitive restructuring for weight/shape concerns and other triggers for binge eating, and relapse prevention [122]. CBT has produced substantial reductions in binge eating as compared to no treatment [123–125] and supportive therapy [126]. The majority of RCTs have reported remission rates greater than 50% [127]. Unfortunately, CBT has generally not produced meaningful weight loss [118,122,127–129], but this may be a contraindicated goal. CBT has demonstrated improvements in a number of features associated with BED including eating disordered psychopathology [122,124,130,131], depression [122,124,130,132], social adjustment [133], and self-esteem [132]. Treatment gains are generally well-maintained at 1-year to 4-year follow-up [122,123,130,133,134]. Individual and group treatments appear to produce similar results [134], and treatment completion rates have been estimated at approximately 80% across different delivery formats [127]. One strength of the CBT literature is the inclusion of participants with severe psychopathology, which facilitates the generalizability of these findings [127].

A number of factors have been associated with treatment outcome in CBT trials. Poor treatment outcomes have been associated with a history of weight problems during childhood, high levels of emotional eating at baseline, interpersonal dysfunction, and low group cohesion during group CBT [110,124,134]. Overvaluation of weight and shape demonstrated a statistical trend toward negatively impacting outcomes in one study. The presence of a cluster B personality disorder (ie, borderline histrionic, antisocial, and narcissistic personality disorders) predicted higher levels of binge eating at 1-year follow-up in a combined sample of participants treated with group CBT or group interpersonal psychotherapy (IPT) [135].