Continuing Education Activity

Binge eating disorder is a psychological condition characterized by episodes of uncontrolled consumption of large amounts of food in a short period, typically <2 hours. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), binge eating disorder involves consuming more food compared to what is typical in similar circumstances at least once a week for 3 months without compensatory behaviors such as purging or excessive exercise. The disorder is also associated with at least 3 of the following behaviors—eating rapidly, eating until uncomfortably full, eating large amounts when not hungry, eating alone due to embarrassment, and feeling disgusted, depressed, or guilty afterward. 

Binge eating disorder is associated with significant distress and impairment in daily life, and its severity ranges from mild, defined as 1 to 3 episodes per week, to extreme with >14 episodes per week. Management involves assessing binge frequency, triggers, and associated emotions and implementing effective treatments, including cognitive behavioral therapy, interpersonal psychotherapy, and dialectical behavioral therapy. Pharmacotherapy and behavioral weight loss strategies may also be beneficial in some patients. This activity for healthcare professionals is designed to enhance the learner's competence in identifying binge eating disorder, performing the recommended evaluation, and implementing an appropriate interprofessional approach when managing the psychological and medical aspects of this condition. 

Objectives:

• Identify the clinical features of binge eating disorders.
• Differentiate binge eating disorder from other eating disorders.
• Assess patients with suspected binge eating disorder.
• Implement interprofessional team strategies to improve care coordination and outcomes in patients with binge eating disorder.

Introduction

Binge eating disorder is a psychological condition characterized by episodes of uncontrolled consumption of large amounts of food in a short period, typically <2 hours. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), binge eating disorder involves consuming more food compared to what is typical in similar circumstances at least once a week for 3 months without engaging in compensatory behaviors such as purging or excessive exercise. The disorder is also associated with at least 3 of the following behaviors:

• Eating much more rapidly compared to normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not feeling physically hungry
• Eating alone due to feeling embarrassed about the quantity consumed
• Feeling disgusted with oneself, depressed, or very guilty afterward [1]

Binge eating disorder is also characterized by the distress the binge eating behavior causes the patients. The severity of BED is categorized based on the frequency of weekly binge eating episodes:

• Mild: 1 to 3 episodes
• Moderate: 4 to 7 episodes
• Severe: 8 to 13 episodes
• Extreme: ≥14 episodes
• In partial remission:<1 episode on average for a sustained period
• In complete remission: 0 episodes for a sustained period

Etiology

Binge eating disorder arises from multiple biological, psychological, social, and cultural factors. Therefore, a sole defined cause has not been identified. The condition has a heritability estimate of 41% to 57%.[2]

Risk Factors for Binge Eating Disorder

Biological risk factors include the following:

• Substance abuse
• DRD2 polymorphisms, mediating reward sensitivity
• OPRM1 polymorphisms, mediating reward sensitivity
• 5-HTT polymorphisms (mixed evidence)
• MC4R polymorphisms (mixed evidence)
• Alterations in gut microbiome [3][4]
• Alterations in cortical connectivity [5]

The following psychological risk factors are also associated with binge eating disorder:

• Premorbid negative affectivity
• Perfectionism

Social and developmental risk factors include the following:

• Conduct problems
• Childhood obesity
• Family weight concerns and eating problems
• Parenting problems and family conflict
• Parental psychopathology
• Physical or sexual abuse
• Childhood loss of control eating, which may be considered a prodrome in adults as well

Epidemiology

Binge eating disorder is more common in women compared to men, often starting in late adolescence or early adulthood. This condition is also more common in students and those without a college education. The lifetime prevalence of binge eating disorder averages 1.9% in international surveys and 2.6% in studies conducted in the United States. Approximately 79% of people with a history of binge eating disorder have at least 1 lifetime psychiatric comorbidity. In an estimated 48.9% of people, ≥3 comorbid conditions are observed, including:

• Anxiety disorder in 56.1%, with phobia being the most common
• Mood disorder in 46.1%, with major depressive disorder being the most common
• Disruptive behavior disorder in 25.4%, with intermittent explosive disorder and attention-deficit/hyperactivity disorder being the most common
• Substance use disorder in 23.7%, with alcohol use disorder being the most common [6]

Compared to individuals without eating disorders, those with binge eating disorders are statistically less likely to have a body mass index (BMI) <25 and are more likely to have a BMI ≥25. However, the precise distribution of these differences varies for each population tested.

Pathophysiology

Research has emphasized the roles of negative affect regulation, alterations in reward processing, and inhibitory control in binge eating disorder.[7] The affect regulation model suggests that binge eating episodes precede and relieve negative affect, although the latter point has been questioned.[8][9] A food addiction hypothesis has been proposed due to similarities between binge eating disorder and substance use disorders in terms of reward processing and inhibitory control. This hypothesis suffers from a lack of evidence of tolerance and withdrawal.[10]

Patients with binge eating disorder demonstrate decreased resting state functional connectivity in the striatum [11] and decreased descending response inhibition from the prefrontal cortex.[12] The inferior frontal gyrus and insula are also dysfunctional in binge eating disorder and typically work in concert with the prefrontal cortex to exert descending control of behavior.[13] Evidence for greater activation of the dorsal anterior cingulate cortex in response to cues related to high-energy-density foods indicates altered reward processing and salience of food.[14] Compared to patients with bulimia nervosa, differences in default mode network connectivity may mediate binge eating disorder's lack of compensatory behavior.[15]

History and Physical

Clinical Assessment

Because binge eating disorder is characterized by episodes of uncontrolled consumption of large amounts of food to various degrees of severity, clinicians must inquire about clinical factors associated with eating disorders. Furthermore, clinicians should evaluate clinical features specific to binge eating disorder. If binge eating disorder is suspected, the clinician should assess the following clinical features to assist with diagnosis:

• Frequency of binge eating episodes
• Triggers for binge eating episodes
• Duration of episodes
• Amount of food consumed during episodes and level of hunger related to an episode
• Feelings associated with the binge, such as loss of control and  negative emotions before or after
• Speed of eating
• Age of onset of binge eating behavior
• Compensatory behaviors, such as purging, exercise, and restriction
• Comorbidities, such as psychiatric and somatic
• Substance abuse
• Family history of psychiatric and somatic [1]

In addition, the patient's nutritional status should be assessed, including:

• Dieting and lifetime weight history
• Physical activity and exercise
• Current eating pattern and dietary choices
• Types of overeating, such as overeating at meals, night eating, snacking, and grazing

Physical examination should include monitoring body weight and identifying potential obesity complications, such as metabolic syndrome, through waist circumference, body mass index, blood pressure, and other clinical indicators.

Evaluation

Psychiatric Screening for Binge Eating Disorder

Several screening questionnaires are used to assess for various eating disorders. Questionnaires used to evaluate binge eating disorders include:

• Binge eating scale [16]
• Three-factor eating questionnaire [17]
• Body shape questionnaire [18]
• Eating disorders examination [19]
• Structured clinical interview for the diagnosis of DSM disorders
• Questionnaire of eating and weight patterns [20]

Additional Evaluation

In patients with suspected binge eating disorder, further evaluation for potential comorbid conditions should also be performed. Medical status evaluation should notably include the following comorbidities associated with obesity and excess body weight:

• Hypertension
• Hyperlipidemia
• Diabetes mellitus
• Gastroesophageal reflux disease
• Hepatobiliary disease
• Coronary artery disease
• Obstructive sleep apnea
• Hypothyroidism

Treatment / Management

Most individuals with eating disorders, including binge eating disorder, do not receive adequate care as the condition is often missed, and patients do not have sufficient access to appropriate resources. Therefore, clinicians should strive to implement evidence-based treatments into routine clinical care and expand access to underserved populations. Goals for patients seeking treatment for binge eating disorder include a reduction in episodes, a reduction in comorbidities, and a reduction in body weight.[21] The American Psychiatric Association (APA) practice guideline for eating disorders recommends initiating treatment with either individual or group psychotherapy using cognitive behavioral therapy or interpersonal psychotherapy. If the patient does not respond to psychotherapy or strongly prefers medication, pharmacotherapy options include lisdexamfetamine, selective serotonin reuptake inhibitors, and other medications. Behavioral weight loss strategies may also be beneficial for managing weight and reducing binge episodes. Transcranial magnetic stimulation and transcranial direct current stimulation are being investigated for use in binge eating disorder.[22]

Psychotherapy

Effective psychotherapy treatments for binge eating disorder include cognitive behavioral therapy, interpersonal psychotherapy, and dialectical behavioral therapy.

Cognitive Behavioral Therapy 

Cognitive behavioral therapy focuses on identifying and changing maladaptive patterns of thought and behavior. Multiple randomized controlled trials have studied cognitive behavioral therapy for binge eating disorder. Patients can be treated through a clinician or a self-help program,[23][24][23] both being equally effective. Cognitive behavioral therapy self-help programs are comparable to behavioral weight loss methods, such as calorie restriction and increased activity, in short-term outcomes and are more effective in specialty settings. Cognitive behavioral therapy has a high rate of abstinence, is well tolerated, and maintains remission for 1 to 2 years. The speed of response to treatment is a good prognostic sign. Self-help programs focus on:

• Creating regular eating patterns
• Monitoring eating habits
• Learning self-control techniques
• Learning problem-solving techniques

Interpersonal Psychotherapy 

Interpersonal psychotherapy focuses on interpersonal stressors, functions, and roles. This psychotherapy modality can take place in a group format or individual format. The improvements in interpersonal function are believed to reduce negative affect and binge eating episodes, focusing on low self-esteem and perfectionism.[25] Interpersonal psychotherapy techniques include:

• Identifying the interpersonal area that links to binge eating episodes.
• Experimentation or constructive changes in problematic interpersonal relations.

Dialectical Behavioral therapy 

Dialectical behavioral therapy focuses on developing tools for affect regulation.[26] This therapy helps patients balance dichotomies in feeling, behavior, and thinking. Patients undergoing dialectical behavioral therapy learn various skills, including:

• Mindfulness
• Distress tolerance
• Emotional regulation
• Interpersonal effectiveness, which is sometimes neglected in studies to avoid overlap with interpersonal psychotherapy 

Pharmacotherapy

Pharmacotherapy should be used as first-line therapy in patients who do not have access to psychotherapy, decline psychotherapy, or prefer medications. The APA recommends starting with selective serotonin reuptake inhibitors or lisdexamfetamine. Medication options include:

• Lisdexamfetamine (the only medication with Food and Drug Administration approval for moderate-to-severe binge eating disorder in adults)[27]
• Selective serotonin reuptake inhibitors, such as sertraline, fluoxetine, fluvoxamine, escitalopram, and citalopram [28]
• Topiramate [29]
• Zonisamide [30]
• Armodafinil [31]
• Methylphenidate [32]
• Atomoxetine [33] 

Behavioral Weight Loss

Behavioral weight loss is an evidence-based strategy that helps with weight loss and reduces binge eating episodes by decreasing caloric intake, increasing activity, and focusing on the nutritional quality of food. If the patient has developed significant physical comorbidities, referring them to a weight loss clinic or bariatric surgeon may be advisable. 

Differential Diagnosis

The following conditions should be considered when evaluating binge eating disorder:

• Obesity: Patients with binge eating disorder are more likely to be obese, but it should not be assumed that every obese patient engages in binge eating. Obese patients with binge eating disorder are more likely to overvalue body weight, have psychiatric comorbidities, and respond to psychotherapy interventions for their weight management. 

• Bulimia nervosa: Binge eating disorder is different from bulimia nervosa because there is no compensatory behavior following excessive eating. Patients with binge eating disorder are less likely to show long-term dietary restrictions to manage their weight compared to those with bulimia nervosa.

• Anorexia nervosa, binge eating or purging type: The distinction between this subtype and binge eating disorder is the lack of compensatory behavior negating excessive eating.

• Borderline personality disorder: Part of the diagnostic criteria for this condition is impulsive behavior, which is self-damaging, with binge eating being a typical example. The binge eating disorder should only be diagnosed if the criteria are met.

• Night eating syndrome: This condition is limited to excessive eating either after the last meal of the day or after waking at night. 

• Mood disorders: An increase in appetite is an element of the diagnostic criteria. In addition, some patients with mood disorders overeat to diminish their distress. The binge eating disorder should only be diagnosed if the criteria are met.

• Anxiety disorders: Some patients with anxiety disorders overeat to diminish their distress, but the binge eating disorder should only be diagnosed if the criteria are met. 

• Kleine-Levin syndrome: A rare parasomnia that includes binge eating, hypersomnia, hypersexuality, and cognitive or behavioral disturbances. 

Prognosis

Longitudinal studies suggest a chronic relapsing and remitting course that is less likely to evolve into another eating disorder compared to bulimia nervosa or anorexia nervosa.[2] Binge eating behavior in children and adolescents is associated with an increased risk of depression, substance use, and excess weight gain.[34] In addition, binge eating behavior worsens the risk of complications from obesity, independent of the degree of obesity.[35]

Complications

Most patients with binge eating disorder are overweight or obese;[36] associated complications of binge eating disorder are related to this include:

• Musculoskeletal pain
• Metabolic syndrome
• Hypertension
• Hyperlipidemia
• Diabetes
• Cardiovascular disease
• Menstrual dysfunction, such as amenorrhea and oligomenorrhea [37]
• Cortisol dysregulation [38][39]
• Sleep disorders, such as apnea and obesity hypoventilation

Deterrence and Patient Education

Patients should be counseled regarding the disorder and how to cope with binges. Awareness of binge episodes and knowledge of strategies for self-control help prevent the cycle of binging and guilt. Over-evaluating body shape and weight produces dysfunctional eating and dieting behavior, which in turn causes physiological and psychological vulnerability to episodes of binge eating.[40] The following interventions should be included in patient education: 

• Monitor eating patterns
• Track meals and snacks
• Limit weight tracking to avoid becoming preoccupied with the number
• Identify and track triggers, such as changes in eating behavior, substance use, and mood or anxiety symptoms
• Avoid people, places, and things that trigger binges

Enhancing Healthcare Team Outcomes

Patients with binge eating disorders should be treated by an interprofessional team, including psychiatrists, endocrinologists, psychologists, pharmacists, nutritionists, social workers, educational professionals, and nurses. Counseling from nutritionists plays an essential role in organizing and planning meals and behavioral weight loss therapy for these patients.[41] As binge eating disorder is associated with comorbid psychological conditions, the involvement of psychologists and social workers is indicated. Clinicians should be well-trained in evaluating and treating patients with this disorder. Bariatric and psychiatric nurses are involved with patient and family education, monitoring of patients, and documentation for the team. Pharmacists evaluate prescribed medications for appropriateness, dosage, and drug interactions and report any concerns to the rest of the team.

Clinicians should be aware that patients with binge eating disorders are vulnerable to shame and stigma and find it distressing to share their symptoms and concerns with healthcare professionals.[42] The management and education should be tailored to the age and level of development. Healthcare professionals should also assess for signs of bullying, teasing, abuse, and neglect. Team members should address any misconception regarding binge eating disorders that the patients or their families might have. The clinician should communicate with the patient nonjudgmentally, and the patient's weight and appearance should be addressed with care. Clinicians should foster a working relationship with those who care for patients with binge-eating disorders.[43] The clinician and all interprofessional team members should show empathy, respect, and compassion and provide suitable information for binge eating disorders and obesity. Family members, guardians, teachers, and peers should also be encouraged to support the patient during treatment. In addition, family members should undergo an assessment for eating disorders. The treatment team should offer emergency plans if the patient is at a high risk of a psychiatric event.

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References

1.

Kornstein SG, Kunovac JL, Herman BK, Culpepper L. Recognizing Binge-Eating Disorder in the Clinical Setting: A Review of the Literature. Prim Care Companion CNS Disord. 2016;18(3) [PMC free article: PMC5035811] [PubMed: 27733955]

2.

Hilbert A. Binge-Eating Disorder. Psychiatr Clin North Am. 2019 Mar;42(1):33-43. [PubMed: 30704638]

3.

Samulėnaitė S, García-Blanco A, Mayneris-Perxachs J, Domingo-Rodríguez L, Cabana-Domínguez J, Fernàndez-Castillo N, Gago-García E, Pineda-Cirera L, Burokas A, Espinosa-Carrasco J, Arboleya S, Latorre J, Stanton C, Hosomi K, Kunisawa J, Cormand B, Fernández-Real JM, Maldonado R, Martín-García E. Gut microbiota signatures of vulnerability to food addiction in mice and humans. Gut. 2024 Jun 26; [PubMed: 38926079]

4.

Terry SM, Barnett JA, Gibson DL. A critical analysis of eating disorders and the gut microbiome. J Eat Disord. 2022 Nov 03;10(1):154. [PMC free article: PMC9635068] [PubMed: 36329546]

5.

Donnelly B, Hay P. Mapping Treatment Advances in the Neurobiology of Binge Eating Disorder: A Concept Paper. Nutrients. 2024 Apr 07;16(7) [PMC free article: PMC11013212] [PubMed: 38613114]

6.

Kessler RC, Berglund PA, Chiu WT, Deitz AC, Hudson JI, Shahly V, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Benjet C, Bruffaerts R, de Girolamo G, de Graaf R, Maria Haro J, Kovess-Masfety V, O'Neill S, Posada-Villa J, Sasu C, Scott K, Viana MC, Xavier M. The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys. Biol Psychiatry. 2013 May 01;73(9):904-14. [PMC free article: PMC3628997] [PubMed: 23290497]

7.

Wu K, Lo YT, Cavaleri J, Bergosh M, Ipe J, Briggs RG, Jann KB, Murray SB, Mason XL, Liu CY, Lee DJ. Neuromodulation of Eating Disorders: A Review of Underlying Neural Network Activity and Neuromodulatory Treatments. Brain Sci. 2024 Feb 22;14(3) [PMC free article: PMC10968923] [PubMed: 38539589]

8.

Dingemans A, Danner U, Parks M. Emotion Regulation in Binge Eating Disorder: A Review. Nutrients. 2017 Nov 22;9(11) [PMC free article: PMC5707746] [PubMed: 29165348]

9.

Haedt-Matt AA, Keel PK. Revisiting the affect regulation model of binge eating: a meta-analysis of studies using ecological momentary assessment. Psychol Bull. 2011 Jul;137(4):660-681. [PMC free article: PMC3100657] [PubMed: 21574678]

10.

Schulte EM, Grilo CM, Gearhardt AN. Shared and unique mechanisms underlying binge eating disorder and addictive disorders. Clin Psychol Rev. 2016 Mar;44:125-139. [PMC free article: PMC5796407] [PubMed: 26879210]

11.

Haynos AF, Camchong J, Pearson CM, Lavender JM, Mueller BA, Peterson CB, Specker S, Raymond N, Lim KO. Resting State Hypoconnectivity of Reward Networks in Binge Eating Disorder. Cereb Cortex. 2021 Mar 31;31(5):2494-2504. [PMC free article: PMC8248831] [PubMed: 33415334]

12.

Veit R, Schag K, Schopf E, Borutta M, Kreutzer J, Ehlis AC, Zipfel S, Giel KE, Preissl H, Kullmann S. Diminished prefrontal cortex activation in patients with binge eating disorder associates with trait impulsivity and improves after impulsivity-focused treatment based on a randomized controlled IMPULS trial. Neuroimage Clin. 2021;30:102679. [PMC free article: PMC8102655] [PubMed: 34215149]

13.

Balodis IM, Molina ND, Kober H, Worhunsky PD, White MA, Rajita Sinha, Grilo CM, Potenza MN. Divergent neural substrates of inhibitory control in binge eating disorder relative to other manifestations of obesity. Obesity (Silver Spring). 2013 Feb;21(2):367-77. [PMC free article: PMC3610836] [PubMed: 23404820]

14.

Geliebter A, Benson L, Pantazatos SP, Hirsch J, Carnell S. Greater anterior cingulate activation and connectivity in response to visual and auditory high-calorie food cues in binge eating: Preliminary findings. Appetite. 2016 Jan 01;96:195-202. [PMC free article: PMC4684801] [PubMed: 26275334]

15.

Stopyra MA, Simon JJ, Skunde M, Walther S, Bendszus M, Herzog W, Friederich HC. Altered functional connectivity in binge eating disorder and bulimia nervosa: A resting-state fMRI study. Brain Behav. 2019 Feb;9(2):e01207. [PMC free article: PMC6379643] [PubMed: 30644179]

16.

Duarte C, Pinto-Gouveia J, Ferreira C. Expanding binge eating assessment: Validity and screening value of the Binge Eating Scale in women from the general population. Eat Behav. 2015 Aug;18:41-7. [PubMed: 25880043]

17.

Stunkard AJ, Messick S. The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. J Psychosom Res. 1985;29(1):71-83. [PubMed: 3981480]

18.

Fernandes HM, Soler P, Monteiro D, Cid L, Novaes J. Psychometric Properties of Different Versions of the Body Shape Questionnaire in Female Aesthetic Patients. Healthcare (Basel). 2023 Sep 20;11(18) [PMC free article: PMC10531348] [PubMed: 37761787]

19.

Berg KC, Peterson CB, Frazier P, Crow SJ. Psychometric evaluation of the eating disorder examination and eating disorder examination-questionnaire: a systematic review of the literature. Int J Eat Disord. 2012 Apr;45(3):428-38. [PMC free article: PMC3668855] [PubMed: 21744375]

20.

Yanovski SZ, Marcus MD, Wadden TA, Walsh BT. The Questionnaire on Eating and Weight Patterns-5: an updated screening instrument for binge eating disorder. Int J Eat Disord. 2015 Apr;48(3):259-61. [PMC free article: PMC4374019] [PubMed: 25545458]

21.

Crone C, Fochtmann LJ, Attia E, Boland R, Escobar J, Fornari V, Golden N, Guarda A, Jackson-Triche M, Manzo L, Mascolo M, Pierce K, Riddle M, Seritan A, Uniacke B, Zucker N, Yager J, Craig TJ, Hong SH, Medicus J. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders. Am J Psychiatry. 2023 Feb 01;180(2):167-171. [PubMed: 36722117]

22.

Bryson C, Douglas D, Schmidt U. Established and emerging treatments for eating disorders. Trends Mol Med. 2024 Apr;30(4):392-402. [PubMed: 38503683]

23.

Striegel-Moore RH, Wilson GT, DeBar L, Perrin N, Lynch F, Rosselli F, Kraemer HC. Cognitive behavioral guided self-help for the treatment of recurrent binge eating. J Consult Clin Psychol. 2010 Jun;78(3):312-21. [PMC free article: PMC2880824] [PubMed: 20515207]

24.

Lynch FL, Striegel-Moore RH, Dickerson JF, Perrin N, Debar L, Wilson GT, Kraemer HC. Cost-effectiveness of guided self-help treatment for recurrent binge eating. J Consult Clin Psychol. 2010 Jun;78(3):322-33. [PMC free article: PMC2880825] [PubMed: 20515208]

25.

Wilson GT, Wilfley DE, Agras WS, Bryson SW. Psychological treatments of binge eating disorder. Arch Gen Psychiatry. 2010 Jan;67(1):94-101. [PMC free article: PMC3757519] [PubMed: 20048227]

26.

American Psychiatric Association. Treatment of patients with eating disorders,third edition. American Psychiatric Association. Am J Psychiatry. 2006 Jul;163(7 Suppl):4-54. [PubMed: 16925191]

27.

Schneider E, Higgs S, Dourish CT. Lisdexamfetamine and binge-eating disorder: A systematic review and meta-analysis of the preclinical and clinical data with a focus on mechanism of drug action in treating the disorder. Eur Neuropsychopharmacol. 2021 Dec;53:49-78. [PubMed: 34461386]

28.

Muratore AF, Attia E. Psychopharmacologic Management of Eating Disorders. Curr Psychiatry Rep. 2022 Jul;24(7):345-351. [PMC free article: PMC9233107] [PubMed: 35576089]

29.

Nourredine M, Jurek L, Auffret M, Iceta S, Grenet G, Kassai B, Cucherat M, Rolland B. Efficacy and safety of topiramate in binge eating disorder: a systematic review and meta-analysis. CNS Spectr. 2021 Oct;26(5):459-467. [PubMed: 32641176]

30.

Buoli M, Grassi S, Ciappolino V, Serati M, Altamura AC. The Use of Zonisamide for the Treatment of Psychiatric Disorders: A Systematic Review. Clin Neuropharmacol. 2017 Mar/Apr;40(2):85-92. [PubMed: 28195838]

31.

McElroy SL, Guerdjikova AI, Mori N, Blom TJ, Williams S, Casuto LS, Keck PE. Armodafinil in binge eating disorder: a randomized, placebo-controlled trial. Int Clin Psychopharmacol. 2015 Jul;30(4):209-15. [PubMed: 26011779]

32.

Quilty LC, Allen TA, Davis C, Knyahnytska Y, Kaplan AS. A randomized comparison of long acting methylphenidate and cognitive behavioral therapy in the treatment of binge eating disorder. Psychiatry Res. 2019 Mar;273:467-474. [PubMed: 30684794]

33.

McElroy SL, Guerdjikova A, Kotwal R, Welge JA, Nelson EB, Lake KA, Keck PE, Hudson JI. Atomoxetine in the treatment of binge-eating disorder: a randomized placebo-controlled trial. J Clin Psychiatry. 2007 Mar;68(3):390-8. [PubMed: 17388708]

34.

Tanofsky-Kraff M, Yanovski SZ, Schvey NA, Olsen CH, Gustafson J, Yanovski JA. A prospective study of loss of control eating for body weight gain in children at high risk for adult obesity. Int J Eat Disord. 2009 Jan;42(1):26-30. [PMC free article: PMC2673525] [PubMed: 18720473]

35.

Olguin P, Fuentes M, Gabler G, Guerdjikova AI, Keck PE, McElroy SL. Medical comorbidity of binge eating disorder. Eat Weight Disord. 2017 Mar;22(1):13-26. [PubMed: 27553016]

36.

McCuen-Wurst C, Ruggieri M, Allison KC. Disordered eating and obesity: associations between binge-eating disorder, night-eating syndrome, and weight-related comorbidities. Ann N Y Acad Sci. 2018 Jan;1411(1):96-105. [PMC free article: PMC5788730] [PubMed: 29044551]

37.

Algars M, Huang L, Von Holle AF, Peat CM, Thornton LM, Lichtenstein P, Bulik CM. Binge eating and menstrual dysfunction. J Psychosom Res. 2014 Jan;76(1):19-22. [PMC free article: PMC3909535] [PubMed: 24360136]

38.

Rosenberg N, Bloch M, Ben Avi I, Rouach V, Schreiber S, Stern N, Greenman Y. Cortisol response and desire to binge following psychological stress: comparison between obese subjects with and without binge eating disorder. Psychiatry Res. 2013 Jul 30;208(2):156-61. [PubMed: 23083917]

39.

Lavagnino L, Amianto F, Parasiliti Caprino M, Maccario M, Arvat E, Ghigo E, Abbate Daga G, Fassino S. Urinary cortisol and psychopathology in obese binge eating subjects. Appetite. 2014 Dec;83:112-116. [PubMed: 25149200]

40.

Ely AV, Cusack A. The Binge and the Brain. Cerebrum. 2015 Sep-Oct;2015 [PMC free article: PMC4919948] [PubMed: 27358667]

41.

Treasure J, Claudino AM, Zucker N. Eating disorders. Lancet. 2010 Feb 13;375(9714):583-93. [PubMed: 19931176]

42.

Becker AE, Hadley Arrindell A, Perloe A, Fay K, Striegel-Moore RH. A qualitative study of perceived social barriers to care for eating disorders: perspectives from ethnically diverse health care consumers. Int J Eat Disord. 2010 Nov 01;43(7):633-47. [PMC free article: PMC3020364] [PubMed: 19806607]

43.

Treasure J, Nazar BP. Interventions for the Carers of Patients With Eating Disorders. Curr Psychiatry Rep. 2016 Feb;18(2):16. [PMC free article: PMC4718944] [PubMed: 26781554]

Disclosure: Jonathan Mars declares no relevant financial relationships with ineligible companies.

Disclosure: Aqsa Iqbal declares no relevant financial relationships with ineligible companies.

Disclosure: Anis Rehman declares no relevant financial relationships with ineligible companies.