Diagnostic overview

• Binge episodes: eating an objectively large amount of food in a discrete period (e.g., within 2 hours) with a sense of loss of control.
• Associated features: eating more rapidly than normal, until uncomfortably full, large amounts when not hungry, eating alone due to embarrassment, and marked distress about bingeing.
• Frequency/duration (DSM‑5): on average ≥1 binge episode/week for 3 months. No regular compensatory behaviours (purging) present.

Clinical features & consequences

• Psychological: shame, guilt, preoccupation with food/weight, low self‑esteem, mood lability and elevated rates of depression and anxiety.
• Physical/medical: overweight/obesity in many patients, metabolic syndrome, type 2 diabetes, dyslipidaemia, hypertension, gastrointestinal symptoms and sleep disturbance.
• Functional impact: social withdrawal, impaired work or school performance, financial consequences from food consumption and relationship strain.

Assessment checklist

1. Detailed eating history: binge frequency, triggers, contexts (alone, night), perceived portion size, duration and associated distress.
2. Medical screen: BMI, waist circumference, blood pressure and baseline labs (glucose/HbA1c, lipids, thyroid function) as indicated.
3. Mental health assessment: mood, suicidality, substance use, impulsivity and comorbid psychiatric diagnoses.
4. Medication review: antidepressants, antipsychotics and mood stabilisers can influence appetite and weight; identify contributors.
5. Use structured tools: Eating Disorder Examination Questionnaire (EDE‑Q), BED screening questions, PHQ‑9, GAD‑7.

Severity specifiers & subtypes

• Severity (DSM‑5): based on binge episodes/week — Mild (1–3), Moderate (4–7), Severe (8–13), Extreme (≥14).
• Specifiers: with/without marked distress about bingeing; presence of nocturnal eating episodes; rapid‑onset vs chronic course.

Evidence‑based psychological treatments

• Cognitive Behavioural Therapy for Eating Disorders (CBT‑E): first‑line psychological treatment — targets binge triggers, dietary restraint, overvaluation of weight/shape, and relapse prevention.
• Interpersonal Psychotherapy (IPT): effective alternative focusing on interpersonal triggers and social functioning; useful when interpersonal problems maintain bingeing.
• Dialectical Behaviour Therapy (DBT)‑informed approaches: target emotion dysregulation and impulsivity leading to binge episodes.
• Family‑Based Treatment (FBT): for adolescents with BED—engages family to support regular eating and reduce secrecy/shame around food.

Pharmacologic options

• Lisdexamfetamine dimesylate (LDX): the only medication specifically approved for moderate‑to‑severe BED in many jurisdictions — reduces binge frequency and improves global functioning; monitor for cardiovascular side effects and abuse potential.
• Antidepressants (SSRIs): fluoxetine, sertraline and others can reduce binge frequency and associated depressive symptoms; effect sizes modest.
• Topiramate: evidence for reducing binge frequency and promoting weight loss but limited by cognitive side effects and teratogenicity—use cautiously and with informed consent.
• Medication choice should be individualised, combined with psychotherapy, and consider comorbidities and pregnancy potential.

Nutritional & behavioural strategies

• Regular structured meals and snacks to reduce extreme hunger and prevent dietary restriction — planned eating is central to CBT‑E.
• Self‑monitoring: food diaries, mood and trigger logs to increase awareness and identify patterns.
• Mindful eating techniques, stimulus control (reduce access to binge foods), and problem‑solving for high‑risk situations.

Medical management & monitoring

• Baseline and periodic monitoring of weight, BP, metabolic profile and medication side effects (especially for LDX and topiramate).
• Coordinate care with primary care for management of obesity, diabetes and cardiovascular risk factors; consider referral to dietitian experienced in eating disorders.

When to refer

• Complex comorbidity (severe mood disorder, substance misuse), treatment resistance, rapid physical deterioration, pregnancy considerations, or diagnostic uncertainty — refer to specialist eating‑disorders service or psychiatry.
• In adolescents and young adults, involve family and consider FBT or specialist paediatric eating‑disorder teams.

Key takeaways

• Binge‑eating disorder is common and treatable — CBT‑E and IPT are first‑line psychotherapies; lisdexamfetamine is an evidence‑based pharmacologic option for moderate‑to‑severe BED where available.
• Assess and manage medical complications (metabolic risk), monitor medication safety and combine psychological, nutritional and medical approaches.
• Address comorbid mood disorders and suicidality promptly; refer to specialist services for complex or refractory cases.