Cover Story

Perhaps the greatest controversy in the field of eating-disorder treatment is the debate over how to treat binge-eating disorder. The condition--currently a provisional category in the Diagnostic and Statistical Manual--is marked by recurrent binge-eating without purging and is typically seen in people who are obese.

Like people with bulimia nervosa, those with binge-eating disorder carry distorted attitudes about eating, shape and weight, as well as mood symptoms such as depression and personality disorders. The disorder affects about 2 percent of the general population and 8 percent of people who are obese.

Because binge-eating disorder involves both weight and eating-disorder concerns, researchers in both the obesity and eating-disorders fields perceive treatment goals through the lens of their own training. On one side of the debate, eating-disorders experts believe binge-eating is best treated by traditional eating-disorder approaches, such as helping patients reduce or eliminate bingeing, improving their self-esteem and body acceptance, and treating underlying psychological problems such as depression and anxiety.

On the other side, obesity experts maintain, it's better to treat the obesity first. They believe that tackling psychological problems without addressing excess weight puts the cart before the horse.

"Public health experts who deal with obesity would say, 'If you're not treating the weight, it's like helping someone get rid of a hangnail and leaving the cancer,'" says Kelly Brownell, PhD, a psychologist who heads the Yale Center for Eating and Weight Disorders and treats people with binge-eating disorder and obesity. "Binge-eating itself is not of public health significance--eliminating it does not address all of the potential long-term sequelae of obesity such as hypertension, stroke and heart attack."

Because the disorder is multifaceted, there are numerous tacks to treat it, believes Columbia University psychiatrist B. Timothy Walsh, MD, who chaired the DSM-IV working group on eating disorders. For example, the literature shows that cognitive behavioral therapy is useful for depression and bulimia, that interpersonal therapy aids depression, and that behavioral weight-loss management can help treat obesity.

"There's a lot going on when you're trying to look at the utility of these interventions," Walsh says. "For many people with binge-eating disorder, you can think of at least three potential targets, and it's not clear whether you should aim at all of them at the same time."

Managed care can make matters worse, he says, because it may only pay for one approach when more may well be needed.

WHAT SHOULD TREATMENT TARGET?

Clinicians who treat binge-eating disorder as an eating disorder say that addressing the specific and general psychopathology that underlies the condition eliminates binge-eating and helps patients feel better about themselves. Treatments that fall into this camp include cognitive behavioral therapy, which addresses a person's thoughts and behaviors about eating and self-image, and interpersonal psychotherapy, which helps a person face and heal rifts in current relationships.

As an example of the effectiveness of interpersonal therapy in treating binge-eating disorder, Denise Wilfley, PhD, a binge-eating disorder expert at San Diego State University, describes a woman she helped using this treatment: The woman had been living in another country, and once she returned to the United States, lost all of her social support. She began to binge-eat, and in addition, developed major conflicts with her son, which added to her level of distress.

Treatment helped the woman address her relationship difficulties with her son and build her social network, both hallmarks of the interpersonal approach. The woman's depression gradually vanished, and at the one-year follow-up, she continued to be binge-free. But treating personal problems is not the only thing these therapies can do, Wilfley maintains. They can also have a positive effect on the very thing obesity experts bark about: clients' weight.

In a study now in press in the Archives of General Psychiatry, Wilfley shows how this might come about. The study, the largest on binge-eating disorder to date, compares outcomes of 162 overweight binge-eating disorder patients. Half received group cognitive behavioral therapy and half received interpersonal therapy. Both therapies showed high long-term success in reducing binge-eating and treating a range of psychological problems.

And for 25 percent of the sample, the therapies also helped reduce weight: Participants who abstained from binge-eating at post-treatment and maintained abstinence at a one-year follow-up lost weight, while those who continued to binge-eat gained weight.

The pattern provides a clue for further interventions, Wilfley believes. "If we help people eliminate binge-eating patterns, it should have an impact on body weight," she notes.

Researchers who are more concerned with obesity, however, argue it's not enough to make weight loss a side issue that may or may not get addressed. The way to go, they believe, is behavioral weight loss, which is usually less expensive, shorter in duration and directly targets obesity.

These researchers make a mirror argument to Wilfley's comments about eating-disorder treatments.

"People who use behavioral weight-loss treatments say that it does eliminate binge-eating--and there is some evidence for this," says G. Terence Wilson, PhD, a psychologist at Rutgers University who was a member of the DSM-IV working group on eating disorders.

It's also true, however, that many obesity treatments don't hold up in the long run.

"There is really no good treatment for obesity," maintains Christopher Fairburn, MD, a psychiatrist and eating disorders expert at the University of Oxford. "Surgery is possibly the best, but it's pretty radical. Drug treatments help about 5 percent of people, but you have to keep taking them indefinitely. And behavioral therapies...everyone relapses," he says. "The psychology of it is very interesting," Fairburn adds. "Losing weight is quite easy. But people can only keep it up for a while, then they tend to just throw in the towel."

But Brownell counters that some programs do work, especially if they include a strong weight-maintenance component. "The estimates are far too pessimistic on weight loss," he argues.

A CLINICALLY TROUBLED SUBGROUP

There's yet another wrinkle in the binge-eating disorder debate: Researchers and clinicians are starting to discover that there are probably two groups of binge-eating disorder patients, one that has disordered eating and obesity but less serious psychological problems; another that displays those same eating disturbances but has more long-term, entrenched psychological difficulties.

A recent study by Yale University psychologist Carlos Grilo, PhD, and colleagues confirms the existence of such a group. In the December 2001 issue of the Journal of Consulting and Clinical Psychology (Vol. 69, No. 6), he and colleagues report that about a third of the 101 binge-eating disorder patients in the study--those who generally showed greater negative affect--also demonstrated more severe eating-related psychopathology and had greater psychological disturbances than the rest of the group. That effect held up over time, Grilo notes in the article, adding to the probability that this is a bona-fide subtype of the disorder.

"There may well be subgroups of patients with high rates of depression and low self-esteem who need specialized treatment," says Wilson. "Others who don't have that degree of pathology might just need behavioral weight loss treatment."

BEST OF BOTH WORLDS?

Meanwhile, some researchers are looking at ways to develop a treatment approach that includes both weight-loss and psychological components.

Research conducted by Stanford University psychiatrist Stewart Agras, MD, for example, shows this may be possible. In a 1997 study reported in the Journal of Consulting and Clinical Psychology(Vol. 65, p. 343-347), he found that people who abstained from binge-eating following specialty eating-disorder treatment were significantly more likely to benefit from weight-loss treatment in both the short and long run.

Some of the questions troubling the field may be addressed in a study planned by Wilfley, Agras and Wilson. Now submitted as a grant proposal to the National Institute on Mental Health, the study plans to compare the effects of three divergent treatments that represent the field's areas of controversy: interpersonal psychotherapy, behavioral weight-loss treatment and a guided self-help intervention developed by Fairburn that's intended to provide a credible, inexpensive treatment alternative. Besides looking at binge-eating and body weight, the study will compare how the treatments affect the subgroup of binge-eating disorder patients with high negative affect noted in Grilo's study.

The debates in the field may simmer down once more data are in, Wilfley comments.

"We're a very young area," she says. "We need the next generation of research to help answer some of the questions that are plaguing our field."

Tori DeAngelis is a writer in Syracuse, N.Y.