of Binge Eating Disorder
MICHAEL J. DEVLIN
The state of the field in pharmacological management of patients with binge eating disorder (BED) is characterized more by questions than by answers. Studies of the risk factors for BED and of its phenomenology suggest that individuals who develop the disorder tend to be characterized by (1) a propensity toward obesity and dieting, and (2) a vulnerability to psychiatric disorders, particularly depression (see Chapter 31). In this regard, BED is similar to bulimia nervosa, except that patients who present for treatment for BED are usually overweight or obese, whereas bulimia nervosa treatment samples are typically of normal weight. In addition, the core behavioral feature of BED, binge eating, is similar to the binge eating seen in bulimia nervosa. It is therefore not surprising that clinical trials of medication for BED have been inspired by treatments of known (shortterm) efficacy for bulimia nervosa or for obesity, namely, antidepressants and appetite suppressants, respectively.
In evaluating the outcome of medication trials for BED, it is important to keep in mind the target symptoms. Overweight or obese patients with BED (i.e., the subgroup recruited for the great majority of BED treatment trials) suffer from (1) a somatic disturbance of weight; (2) a behavioral disturbance of eating; (3) often a psychological disturbance of body weight/shape-related distress and, sometimes, depressive features. Any or all of these features are potential targets for treatment, and patients may selectively improve in one or more areas. It is also crucial to consider the long- as well as short-term outcome. Treatments that are helpful in the short term may fail to demonstrate any advantage when examined 1 to 5 years later and, arguably, may interfere with other forms of treatment. For patients who are doing well with short-term medication treatment, it is important to consider the effect of medication discontinuation or, alternatively, the pros and cons of chronic medication treatment.
Thus, the question in evaluating medication treatments for BED is not simply: Do medications work? Rather, one must ask: Are medications helpful in the short- and longterm? If so, what features of BED do they treat? Might they be a useful adjunct to psychological treatments? At what stage of treatment are they most useful? Are particular