14  Treatment of Binge Eating, Including Bulimia Nervosa and Binge-Eating Disorder

Loren Gianini, Ph.D.
Allegra Broft, M.D.
Michael Devlin, M.D.

In this chapter, we provide an overview of the general approach to treating binge eating that is typically seen in the context of bulimia nervosa (BN) or binge-eating disorder (BED). We discuss evidence-based psychotherapeutic and pharmacological treatments for BN and BED, as well as other promising treatment approaches. The reader is encouraged to view Video 2 for sample questions regarding the preliminary assessment of binge eating and compensatory behaviors by a general practitioner.

images Video Illustration 2: Assessing eating problems in the primary care setting (3:24)

General Approach to the Treatment of Binge Eating

Normalization of Eating

The primary goal of treatment for individuals with either BN or BED is the normalization of eating behavior. The common behavior shared by these conditions is binge eating, and an important focus of interventions for BN and BED is to eliminate both objective binge episodes (i.e., episodes during which abnormally large amounts of food are consumed with a sense of loss of control) and subjective binge episodes (i.e., episodes in which a normal amount is consumed with a sense of loss of control) (see also Chapter 2, “Eating Problems in Adults” and Chapter 5, “Assessment of Eating Disorders and Problematic Eating Behavior in Bariatric Surgery Patients”). For individuals with BN, an additional goal is to eliminate inappropriate behaviors undertaken to compensate for binge episodes or for other forms of eating; these behaviors include vomiting, use of laxatives or diuretics, and excessive or compulsive exercise. Some individuals with BED and the majority with BN engage in some type of dietary restraint or rigid dietary rules, although success in adhering to these rules may be sporadic, especially for those with BED (Carrard et al. 2012). Restriction may consist of attempts to eat very little throughout the day or strict rules about what can and cannot be eaten (e.g., no sweets, no high-fat foods), and it has been linked to the maintenance of binge eating. Thus, a common goal of treatment is to increase dietary flexibility and ensure that individuals eat on a regular basis and in a manner that meets their daily caloric needs.

Overvaluation of Shape and Weight

In addition to targeting maladaptive eating behaviors, another common goal in treating binge eating is reducing the overvaluation of body shape and weight. This overvaluation is typically defined as self-evaluation that is unduly influenced by an individual’s perception of his or her body shape or weight. Body shape may refer to the overall shape and size of the body or of a particular body area (e.g., stomach, buttocks), whereas body weight refers to the number on the scale. The self-evaluation of individuals with BN, by definition, is influenced by shape and weight to an impairing degree; however, this presentation is also seen in a significant portion of individuals with BED, and it is associated with heightened eating pathology, depression, and worsened treatment outcomes (Grilo et al. 2012b). Overvaluation of shape and weight is often entrenched and difficult to change during the course of treatment, although significant inroads can be made in this area. Treatment follow-up studies in BN have also demonstrated that when body image disturbance is high following treatment, individuals are at heightened risk of poor outcomes and relapse (Keel et al. 2005).

Weight Management

Many individuals with BED, and a smaller subset of individuals with BN, who present for treatment in clinical settings have a body mass index (BMI) in the overweight or obese range (> 25 kg/m2; Bulik and Reichborn-Kjennerud 2003; Masheb and White 2012). These individuals are at increased risk for presenting with obesity-related medical complications such as hypertension and type 2 diabetes. Furthermore, some evidence suggests that in the 12 months prior to entering treatment, a significant portion of individuals with BED report gaining upward of 15 pounds (Blomquist et al. 2011). Therefore, weight management may be included as a component of treatment for binge eating; however, caution should be observed so as not to reinforce preoccupation with shape or weight.

Evidence-Based Treatments for Bulimia Nervosa and Binge-Eating Disorder

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is a brief, present-focused treatment with a strong evidence base for both BN and BED. CBT is considered the treatment of choice for BN, with a Cochrane Review demonstrating the superiority of CBT over no treatment, wait-list control, and other psycho-therapies with regard to reductions in binge eating, purging, and depression (Hay et al. 2009). CBT can effectively eliminate binge eating and purging behaviors in 30%-50% of patients with BN. A large portion of patients who are not abstinent from binge eating or vomiting experience meaningful reductions in symptoms, including improvements in dietary restraint, eating, and weight and shape concerns, at the end of treatment and in long-term follow-up (Fairburn et al. 1995). Similarly, CBT reduces or eliminates binge eating in 50%-60% of patients with BED, and it is superior to behavioral weight loss treatment and pharmacological interventions (Grilo et al. 2005, 2012a).

CBT for BN and BED, as manualized by Fairburn (2008), is rooted in the hypothesis that individuals’ eating disorders are maintained by mal-adaptive thoughts and beliefs (i.e., overvaluation of shape and weight) that lead to maladaptive behaviors (i.e., binge eating, compensatory behaviors, restrictive eating) and vice versa. An important first step in treatment is creating an individualized “formulation” in which the clinician and patient work together to visually diagram the reinforcing relationship between the eating-disordered thoughts and behaviors experienced by the patient (Figure 14-1). Creation of this formulation is intended to increase the patient’s interest in and understanding of the mechanisms maintaining the disorder. It can also help direct the patient to what thoughts and behaviors will be targeted in the treatment and why.

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FIGURE 14–1. Individualized cognitive-behavioral therapy formulation of bulimia nervosa (patient’s wording).

Self-monitoring of eating behavior is a cornerstone of CBT for BN and BED. Traditionally, clinicians provide patients with preprinted self-monitoring forms that allow for tracking of food consumed; the presence of binge eating, purging, or other eating-disordered behaviors; and the context (time, place, thoughts) of the eating episode. Electronic applications with self-monitoring capabilities for smartphones and/or computers are also now available (see Chapter 12, “Application of Modern Technology in Eating Disorder Assessment and Intervention”). Patients are encouraged to monitor for the duration of treatment in real time and to record what they have eaten as closely to the eating episode as possible (Figure 14-2). Self-monitoring has two purposes: First, it allows the clinician and patient to work together to identify and effectively target mal-adaptive eating patterns; they can also use monitoring logs to track progress and identify what is going well for the patient. Second, the act of monitoring eating behavior in real time may have the effect of reducing eating-disordered behaviors. It is thought that having to write down and share details of eating-disordered episodes may dissuade patients from engaging in these behaviors in the moment. It is also possible that realtime monitoring leads to heightened self-awareness of one’s actions, and patients may feel they have more agency over their decisions in the moment and may opt out of eating-disordered behaviors.

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FIGURE 14–2. Example of eating behavior self-monitoring form.

Following successful self-monitoring, patients are typically prescribed a pattern of “regular eating,” or three meals and two to three snacks per day. Patients are encouraged to eat every few hours and to let no more than 4 hours elapse between eating episodes. Regular, frequent meals and snacks reduce disordered eating behaviors because significant dietary restriction (e.g., going more than 4 hours without eating) increases food craving and binge eating. Aberrant eating patterns among individuals with BN and BED may result in abnormal sensations of hunger and satiety, along with other physiological signals that would typically help initiate or terminate eating (e.g., slowed gastric emptying in BN; Devlin et al. 1997). Often, the maintenance of a pattern of regular eating will greatly reduce the frequency of binge episodes. For residual binges, techniques such as stimulus control, urge surfing (a strategy for systematic delay of disordered behavior such as binge eating or purging), or use of distraction are often implemented.

Patients are asked to weigh themselves once weekly at treatment sessions. Those weighing themselves more often are educated about the deleterious effects of frequent weighing, namely, the manner by which this behavior reinforces preoccupation with weight, and about normative fluctuations in weight even while weight is stable. Weighing provides both the patient and the clinician with objective information about the effect of regular eating on the patient’s weight. CBT clinicians also provide patients with psychoeducation regarding the typical nature of dieting, binge eating, and compensatory behaviors (and their relative ineffectiveness as weight-control strategies) within the context of BN and BED.

The initial focus of CBT for BN and BED is behavioral, and after the disordered eating behaviors are better managed, the treatment shifts to addressing thoughts. To start, the cognitive distortions that are targeted are those that relate to eating behavior and dietary rules (e.g., “Eating carbohydrates will make me fat”). Next, thoughts (and related behaviors) that maintain an overvaluation of shape and weight are tackled. The clinician may target beliefs, such as “If I feel fat, it means that I am fat,” or behaviors, such as body checking and body comparisons, that reinforce maladaptive shape- and weight-related thoughts. Patients are encouraged to increase participation in activities not focused on shape and weight to expand the number of options the patients have for self-evaluation and ultimately to detract from the prominence of body weight and shape in determining self-worth.

CBT typically concludes with a progress-maintenance/relapse-prevention phase focused on short-term and long-term maintenance plans. This phase includes 1) steps to minimize the likelihood that a relapse will occur, 2) identification of warning signs that the patient is beginning to slip back into eating-disordered thoughts and behaviors, and 3) development of specific, actionable plans for what the patient can do if this occurs.

Fairburn (2008) also developed an enhanced version of CBT (CBT-E) that can be applied transdiagnostically across eating disorders. CBT-E allows for broad and focused treatment courses. The focused treatment strictly addresses reducing core eating disorder psychopathology, whereas the broad treatment addresses other issues that may help maintain eating pathology, such as perfectionism, low self-esteem, and interpersonal difficulties. Interpersonal difficulties are addressed through the simultaneous implementation of CBT and an abbreviated version of interpersonal psychotherapy (IPT; discussed in more detail in the section “Interpersonal Psychotherapy”). Studies assessing the efficacy of CBT-E in treating BN and BED are limited. For individuals with binge-eating behavior, one randomized controlled trial (RCT) found significant improvements in eating pathology with both the broad and focused versions of CBT-E in a sample of patients with BN and eating disorder not otherwise specified, with the broad version potentially being more effective for individuals with complex psychopathology (Fairburn et al. 2009).

CBT for BN and BED can be delivered in either pure or guided self-help formats. In the pure version, patients typically follow a treatment book without clinical interaction, whereas patients receiving guided self-help typically have at least brief meetings with a clinician to implement the treatment. Evidence suggests that self-help treatments are significantly more effective than wait-list control conditions in reducing binge-eating and purging behaviors; however, it is unclear whether pure self-help and guided self-help are equally efficacious, and evidence suggests that self-help interventions may be less potent than more intensive face-to-face treatments (Sysko and Walsh 2008).

Interpersonal Psychotherapy

IPT was originally developed as a brief, time-limited intervention for the treatment of depression and was subsequently modified for the treatment of both BN and BED (Murphy et al. 2012). IPT focuses primarily on helping patients identify and address current interpersonal problems that are hypothesized to maintain and perpetuate their eating disorders; healthy interpersonal functioning is posited as necessary for psychological well-being. Because individuals with BN and BED report a significant number of interpersonal difficulties, including deficits in social problem solving, loneliness, and poor self-esteem (Ansell et al. 2012), this approach may be particularly appealing to patients. Within the IPT framework, binge eating is theorized to occur as a response to interpersonal disturbances (e.g., social isolation) and consequent negative mood (Fairburn et al. 1993).

A distinguishing feature of IPT is the assignment of the “sick role” to the patient. This process involves presenting patients with a formal diagnosis of an eating disorder and emphasizing the importance of focusing their efforts on treatment and recovery, as one would with any medical illness, even if this means that other responsibilities take a backseat during the duration of treatment. In contrast to CBT, IPT does not so overtly focus on the modification of disturbed eating behaviors or overvaluation of shape and weight.

During the course of IPT, clinicians work with patients to identify typical types of interpersonal problems and determine what the patient can do to effectively address these issues. As a first step toward identifying interpersonal difficulties, the clinician takes an extensive interpersonal history, including an inventory of the patient’s significant relationships. The patient is requested to reflect on how the development of eating disorder symptoms interacted with relationships in the past. The clinician also assesses current interpersonal functioning and the effect of the eating disorder on current relationships. Through this assessment process, one or more primary problem areas are identified and become an area of focus in treatment; these areas include role transitions, interpersonal role disputes, grief, and interpersonal deficits. Role transitions frequently include such situations as beginning new employment, graduation, marriage, or the dissolution of an intimate relationship; role disputes might include conflicts an individual has about what is expected given a particular role (e.g., at work, as a family member); grief may be related to the loss of a person, relationship, or an important piece of one’s identity; and interpersonal deficits usually refers to instances when an individual lacks significant relationships, which may be due to poor social skills. Clinicians encourage mastery of current social roles as well as adjustment to evolving interpersonal situations (Wilfley et al. 2002). A primary goal of treatment is to help mitigate or resolve these interpersonal difficulties in a way that in turn promotes the abstinence from eating-disordered behaviors. To this end, eating disorder symptoms can be linked consistently back to their role in the perpetuation or maintenance of the patient’s interpersonal domain of focus (Tanofsky-Kraff and Wilfley 2010).

IPT is effective in the reduction and elimination of binge eating and purging in BN, although it is somewhat less effective than CBT (Agras et al. 2000). In a multisite trial comparing CBT with IPT in 220 individuals with BN, 45% of individuals in the CBT treatment condition had attained abstinence from binge eating and purging at the end of treatment, compared with 8% of individuals in the IPT treatment arm (Agras et al. 2000). At 12-month follow-up assessment, 40% of the individuals who had completed CBT had achieved abstinence, compared with 27% of those completing IPT, a difference that was not statistically significant.

Although the existing evidence indicates that CBT is superior to IPT in the treatment of BN, CBT and IPT appear to be equally efficacious in the treatment of BED, both immediately following treatment and in longer-term follow-up (Wilfley et al. 2002; Wilson et al. 2010). For example, a large study comparing CBT and IPT in the treatment of patients with BED found that 73% of individuals in the IPT condition achieved remission from binge eating at the end of treatment, compared with 79% of individuals in the CBT condition (Wilfley et al. 2002). At the time of a 12-month follow-up, 62% of individuals in the IPT condition reported abstinence from binge eating, compared with 59% in the CBT condition. Subgroup analyses suggest that individuals with BED are heterogeneous, which may affect overall treatment outcome. Patients with BED experiencing the most mood symptoms and high shape and weight concerns appeared to derive more benefit from IPT, and patients with increased eating disorder pathology experienced greater improvements from CBT (Sysko et al. 2010).

Pharmacotherapy

Bulimia Nervosa

Although several medications are efficacious for the treatment of BN, the role of pharmacotherapy is often best viewed as adjunctive. Some evidence suggests that the combination of pharmacotherapy and psychotherapy may be more efficacious than either intervention alone, but pharmacotherapy alone may be inferior to psychotherapy alone (Hay et al. 2001). Therefore, pharmacotherapy should be considered as a standalone treatment for BN primarily when evidence-based psychotherapy is not feasible or has not been successful. The mechanism by which pharmacological interventions produce clinical improvement in BN is unknown.

Antidepressant medications, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and monoamine oxidase inhibitors (MAOIs), are the most commonly studied classes of medications for the treatment of BN. Comprehensive reviews of placebo-controlled RCTs indicate that each of these classes of medications is significantly more effective than placebo in reducing binge eating, purging, and depression (Flament et al. 2012). Although MAOIs and TCAs alleviate symptoms in BN, both classes of medication have a number of problematic side effects and the potential for fatal overdose; therefore, they are not recommended as first-line treatments for BN and are not typically used. Furthermore, use of MAOIs involves maintaining a tyramine-free diet, which places several restrictions on types of foods that can be safely consumed, and thus may be especially problematic for individuals with disordered eating (Schatzberg et al. 2010).

The SSRI fluoxetine is the most widely studied medication for BN and was approved by the U.S. Food and Drug Administration (FDA) for this diagnosis. Therefore, it is considered to be the pharmacological intervention of choice for individuals with BN. Fluoxetine is typically prescribed at a dosage of 20 mg/day for the treatment of depression; however, a 60-mg/day dosage is significantly more effective in reducing binge eating, purging, weight and shape concerns, and depression among patients with BN. Therefore, this higher dosage is typically recommended (Fluoxetine Bulimia Nervosa Collaborative Study Group 1992; Romano et al. 2002). The common side effects of fluoxetine and other SSRIs are milder and better tolerated by patients than those of MAOIs and TCAs. Other SSRIs that produce meaningful reductions in symptoms (albeit in fewer trials than with fluoxetine) include citalopram (Leombruni et al. 2006), fluvoxamine (Fichter et al. 1997), and sertraline (Milano et al. 2004). One additional non-antidepressant medication option for BN is the anticonvulsant topiramate. Topiramate acts as a γ-aminobutyric acid (GABA) receptor agonist and glutamate receptor antagonist and may alleviate symptoms by improving regulation of appetite and impulsive behaviors. In placebo-controlled RCTs, frequency of binge eating and purging decreased significantly more in the topiramate condition than in the placebo condition (Nickel et al. 2005). Furthermore, individuals in the topiramate condition experienced significant reductions in weight compared with individuals in the placebo group. Therefore, before prescribing topiramate for BN, it may be important to consider the BMI of a patient and the potential implications (both positive and negative) of weight loss.

Most RCTs examining the efficacy of medications in the treatment of BN have been relatively short in duration (e.g., approximately 8 weeks). Of the few trials that have followed patients for significantly longer periods of time, dropout rates have been high (Romano et al. 2002), and therefore the ideal length of pharmacotherapy for BN is unknown. (A minimum of 6-12 months of treatment is consistent with evidence-based recommendations for the pharmacological treatment of depression and is often recommended for patients with BN in the absence of other clarifying data.)

Of note, there has been one placebo-controlled RCT using the antidepressant bupropion, and this trial was discontinued prematurely after 4 of 55 patients taking bupropion experienced grand mal seizures (Horne et al. 1988). As a result, use of bupropion is currently contraindicated in the treatment of BN.

Binge-Eating Disorder

Lisdexamfetamine dimesylate, a dextroamphetamine prodrug, has recently received FDA approval for the treatment of BED (McElroy et al. 2015). Long-term efficacy of this medication has not yet been assessed. Whereas several antidepressant medications have been associated with short-term reduction in binge eating, no particular antidepressant medication has been found to be superior to others. A 2008 meta-analysis analyzing seven studies of SSRIs (i.e., citalopram, fluoxetine, fluvoxamine, sertraline) and a TCA (imipramine) in short-term trials indicated that significantly more participants experienced remission from binge eating in the active medication conditions than in the placebo condition (40.5% vs. 22.2%; Stefano et al. 2008). Although these results are promising, no long-term studies of the efficacy of antidepressants in BED have been conducted, and the durability of these short-term improvements remains untested.

Many individuals with BED have BMIs in the overweight or obese range, and most seeking treatment for their binge eating identify weight loss as a goal of treatment. For this reason, the efficacy of the anticonvulsants topiramate and zonisamide, both of which can have the side effect of weight loss, has been examined in the treatment of BED. Topiramate has been studied in three trials (Claudino et al. 2007; McElroy et al. 2003, 2007). When topiramate was employed in the absence of psychotherapy, intent-to-treat analyses showed superior rates of binge-eating remission in the topiramate groups (58%-64%) compared with the placebo groups (29%-30%; McElroy et al. 2003, 2007). Furthermore, the active medication groups experienced significantly greater reductions in weight than did the placebo groups (5.9 kg vs. 1.2 kg). In a study comparing topiramate and CBT with placebo and CBT, 83.3% of those in the topiramate group and 61.1% of those in the placebo group achieved binge-eating remission during the 21-week trial (Claudino et al. 2007). Despite these benefits, the side effects associated with topiramate can be difficult to tolerate, and treatment adherence can be a problem with this medication. In an open-label extension trial of topiramate lasting 42 weeks, McElroy et al. (2004) found that 68% of study participants failed to complete the trial, with adverse events and nonadherence to treatment being among the primary reasons cited for discontinuation. Similarly, one RCT used zonisamide and found it to be associated with significant reductions in both binge eating and weight. Side effects were similar to those seen with topiramate and were not well tolerated by study participants (McElroy et al. 2006).

Currently, there are four FDA-approved medications for weight loss: lorcaserin, naltrexone-bupropion, orlistat, and phentermine-topiramate. Of these, only orlistat, a pancreatic lipase inhibitor, has been studied in individuals with BED; in these studies, the medication was combined with either a guided self-help version of CBT (Grilo et al. 2005) or a very low calorie diet (Golay et al. 2005). Orlistat does not appear more effective than placebo in achieving remission from binge eating, but there is some evidence that compared with placebo, it causes greater weight loss and that the loss is better maintained after a 3-month follow-up period (Golay et al. 2005; Grilo et al. 2005).

Other Promising Psychotherapies

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is a behaviorally focused outpatient intervention that is efficacious in the treatment of borderline personality disorder (Linehan 1993). DBT is based on a model that views maladaptive behaviors, such as self-injury, as attempts to regulate distressing emotions. Because negative affect often precedes binge eating and other eating-disordered behaviors, affect regulation has been hypothesized as a maintaining mechanism, and therefore a treatment such as DBT may be indicated (Haedt-Matt and Keel 2011). DBT was adapted for BED and BN by Safer et al. (2009), and it directly targets binge eating, purging, mindless eating, and any other behaviors that appear to interfere with progress in psychotherapy. As currently manualized, DBT for BED and BN includes modules devoted to teaching and developing mindfulness skills, including eating mindfully, distress tolerance, and emotion regulation skills. A strong emphasis is placed on daily monitoring of eating-disordered behaviors, concurrent mood states, and use of skills taught during sessions via diary cards.

Although there have been few trials of DBT in treating BN and BED, the results of extant studies have been promising. In a small trial comparing DBT with a wait-list control condition for patients with BED, 89% (16 of 18) of those in the DBT group experienced remission from binge eating and improvements in general eating pathology, compared with 12% (2 of 16) of those on the wait list (Telch et al. 2001). In a larger trial, 101 adults with B ED were randomly assigned to 20 group sessions of either DBT or supportive psychotherapy (Safer et al. 2010). At posttreatment, 64% of patients in the DBT group had achieved abstinence from binge eating, compared with 36% in the supportive psychotherapy group, which was a significant difference. At 12-month follow-up, this significant difference had disappeared, with 64% of DBT patients and 56% of supportive psychotherapy patients maintaining abstinence. Notably, attrition for DBT was lower, in that only 4% of those receiving DBT dropped out of treatment, whereas 33.3% of patients in the supportive psychotherapy condition prematurely discontinued treatment. In patients with BN, a smaller trial comparing 20 weeks of individual DBT to a wait-list control condition found that by the end of treatment, 29% of participants (4 of 14) in the DBT condition had achieved abstinence from bingeing and purging, whereas none of the 15 patients in the wait-list control condition experienced remission, representing a statistically significant difference (Safer et al. 2001).

Integrative Cognitive-Affective Therapy

Integrative cognitive-affective therapy (ICAT) is a brief, present-focused therapy developed for the outpatient treatment of BN (Wonderlich et al. 2008). ICAT is similar in many ways to other therapies such as CBT and DBT; for example, patients are instructed to engage in a regular pattern of eating meals and snacks throughout the day and to track this behavior for analysis during sessions, although meal planning may be more prescriptive and detailed in nature than in these other therapies. In addition, ICAT emphasizes the role of interpersonal patterns in the maintenance of disordered eating, especially through the activation of negative affective states, which may, in turn, lead to emotionally driven disordered eating behaviors. Maladaptive interpersonal styles and negative emotions are first identified and then addressed through the use of targeted interventions. The use of electronic technologies, such as personal digital assistants, is integrated into treatment so that patients can track their emotions and use of skills taught during treatment sessions.

In the first RCT studying ICAT for patients with BN, Wonderlich et al. (2014) compared 21 sessions of ICAT with CBT-E among 80 adults with BN. At the end of treatment, 37.5% of individuals randomly assigned to the ICAT condition and 22.5% of those in the CBT-E condition had achieved abstinence from binge eating and purging; the difference was not statistically significant. At the 4-month follow-up assessment, 32.5% of individuals randomly assigned to ICAT and 22.5% of individuals randomly assigned to CBT-E reported abstinence from these behaviors; again, this was not a statistically significant difference. These results are promising and suggest that ICAT is an intervention worthy of further study.

Conclusion

The primary objective of the treatment of BN and BED is the normalization of eating. Reduction of overvaluation of shape and weight is often an additional target of treatment. Weight management is sometimes an additional treatment target. Because of the strong evidence base for the use of CBT in the treatment of BN, CBT should be considered the treatment of choice. IPT and pharmacotherapy (SSRIs, fluoxetine in particular) should be considered as viable alternatives when CBT is not available. CBT and IPT both have very strong evidence supporting their efficacy in the treatment of BED, and although no individual medication has emerged as superior, pharmacotherapy may also confer significant benefit and reductions in binge eating in this group.

Key Clinical Points

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