Binge eating disorder (BED) is recurrent binge eating without compensatory behaviors, recognized as a distinct diagnosis in DSM-5 (previously a research diagnosis). It is the most prevalent eating disorder — affecting approximately 2-3% of adults at some point. Often missed in primary care and rarely volunteered by patients.
DSM-5 criteria: recurrent binge eating episodes (eating large amounts in a discrete time period with loss of control), with three or more of: eating rapidly, eating until uncomfortably full, eating large amounts when not hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty afterward; marked distress about binge eating; frequency at least once weekly for 3 months; no compensatory behaviors (distinguishes from bulimia); does not occur exclusively during anorexia or bulimia.
Clinical presentation: patient often presents for weight management or related complications rather than for binge eating directly. Substantial shame and concealment. Often hidden binge eating in secret (alone, late at night), followed by self-disgust. The patient may try to compensate the next day through restrictive dieting, which often triggers the next binge — a cycle that perpetuates the disorder.
Comorbidities and complications:
Obesity — 40-70% of BED patients are also obese, with associated metabolic complications (diabetes, hypertension, dyslipidemia, cardiovascular disease).
Mood disorders — depression in 50%+; anxiety also common.
Substance use disorders — particularly when binge eating provides similar emotion-regulation function as substance use.
Sleep disturbances, particularly when binges occur late at night.
Treatment:
CBT for Binge Eating Disorder (CBT-BED) — first-line psychotherapy with strongest evidence. Manualized protocol addressing binge eating patterns, cognitive distortions about food and body image, alternative coping strategies.
Lisdexamfetamine (Vyvanse) — FDA-approved for moderate-to-severe BED. The first medication with this specific indication. Reduces binge eating frequency substantially. Stimulant — monitor for cardiovascular issues, substance use disorder history, abuse potential.
Topiramate — off-label evidence for binge reduction. Side effects (cognitive effects, kidney stones, paresthesias) limit use for some patients.
SSRIs — fluoxetine has some evidence; less robust than for bulimia. Useful particularly when comorbid depression contributes.
Interpersonal psychotherapy (IPT) — alternative to CBT with evidence for BED.
Bariatric surgery considerations — BED should be identified before bariatric surgery; untreated BED predicts poorer surgical outcomes. Surgical centers increasingly screen for and treat BED pre-operatively.
Weight management considerations: dieting alone is generally not the right primary approach for BED — restrictive dieting often triggers binge cycles. Address the binge eating first; weight management often follows or improves as binges reduce.
When you encounter a patient with weight management struggles plus secret binge eating, BED is the diagnosis. Treatment is effective. The interventions exist; the disorder is often hidden until specifically asked about. Open empathetic inquiry about eating patterns reveals what spontaneous reporting often does not.