Guideline sources The following summarized guidelines for the evaluation and management of binge eating disorder (BED) are prepared by our editorial team based on guidelines from the American Psychiatric Association (APA 2023; 2006), the The Scottish Intercollegiate Guidelines Network (SIGN 2022), the U.S. Preventive Services Task Force (USPSTF 2022), the Canadian Practice Guidelines (CPG 2021; 2020), the American College of Endocrinology (ACE/AACE 2016), the American Association of Family Physicians (AAFP 2015), the American Academy of Child and Adolescent Psychiatry (AACAP 2015), and the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2014). 1 2 3 4 5 6 7 8 9 10 Calculator DSM 5 diagnostic criteria for bin Guidelines https://web.pathway.md/diseases/recTfpNVEFkYzkUO6 1/6 6/29/23, 3:17 AM Binge eating disorder Pathway 1. Screening and diagnosis Indications for screening: As per APA 2023 guidelines, screen for the presence of an eating disorder as part of an initial psychiatric evaluation. B As per SIGN 2022 guidelines: Consider screening for the presence of eating disorders as part of the routine review of patients with T1DM. C Elicit history of current or past history of eating disorders in females during pregnancy and postnatal period, recognizing the potential barriers for disclosure. A As per USPSTF 2022 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for eating disorders in adolescents and adults. I As per AACE 2016 guidelines, screen for BED and night eating syndrome in patients with overweight or obesity eligible for weight-loss therapy. B As per AACAP 2015 guidelines, screen all pediatric and adolescent patients for eating disorders seen by a mental health clinician, followed by a comprehensive diagnostic evaluation (including laboratory tests and imaging studies as indicated) if positive. B 2. Diagnostic investigations Initial evaluation: As per APA 2023 guidelines, assess the following during the initial evaluation of patients with a possible eating disorder: height and weight history (maximum and minimum weight, recent weight changes) presence of, patterns in, and changes in restrictive eating, food avoidance, binge eating, and other eating-related behaviors (rumination, regurgitation, chewing, and spitting) patterns and changes in food repertoire (breadth of food variety, narrowing or elimination of food groups) presence of, patterns in, and changes in compensatory and other weight control behaviors, including dietary restriction, compulsive or driven exercise, purging behaviors (laxative use, self-induced vomiting), and use of medication to manipulate weight percentage of time preoccupied with food, weight, and body shape prior treatment and response to treatment for an eating disorder psychosocial impairment secondary to eating or body image concerns or behaviors family history of eating disorders, other psychiatric illnesses, and other medical conditions (obesity, IBD, diabetes mellitus). B Show 2 more As per RANZCP 2014 guidelines, include the following in the assessment of adult patients with possible BED: https://web.pathway.md/diseases/recTfpNVEFkYzkUO6 2/6 6/29/23, 3:17 AM Binge eating disorder Pathway elicit history enquiring into any binge eating, dietary restriction and/or fasting, compulsive or driven exercise, or additional weight control behaviors assess for cognitions of weight and/or shape overvaluation, and body image and eating preoccupations assess for any past history of eating disorders or other psychiatric comorbidities perform a physical examination, including measurement of weight, height, BMI calculation, pulse rate, and BP consider obtaining cardiovascular evaluation and an ECG as clinically indicated consider obtaining serum biochemistry and random glucose as clinically indicated consider involving a general practitioner and/or dentist as appropriate. B Laboratory tests: obtain a CBC and a comprehensive metabolic panel including electrolytes, liver enzymes, and renal function tests in the laboratory assessment of patients with a possible eating disorder. B Electrocardiogram: obtain an ECG in patients with a restrictive eating disorder, severe purging behavior, or taking medications known to prolong the QTc interval. B Screening for comorbidities: As per AAFP 2015 guidelines, assess for psychiatric comorbidities, including depression and suicide risk, anxiety disorders, and substance use disorders, in patients with an eating disorder. B As per RANZCP 2014 guidelines, assess for any past history of eating disorders or other psychiatric comorbidities in patients with BED. B Screening for comobidities: as per APA 2023 guidelines, assess for co-occurring health conditions, including psychiatric disorders, in the initial psychiatric evaluation of patients with a possible eating disorder. B 3. Medical management Multidisciplinary care: As per APA 2023 guidelines, provide a documented, comprehensive, culturally appropriate, and person-centered treatment plan incorporating medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team, in patients with an eating disorder. B As per AACAP 2015 guidelines, ensure a multidisciplinary team approach (developmentally aware, sensitive, and skilled in the care of pediatric and adolescent patients with eating disorders) for the treatment of eating disorders in young patients. B As per AAFP 2015 guidelines, ensure an interdisciplinary team approach, often including a family physician, a psychotherapist or psychiatrist, a dietitian, an eating disorder specialist, and school personnel, for the treatment of patients with bulimia nervosa. B Setting of care: https://web.pathway.md/diseases/recTfpNVEFkYzkUO6 3/6 6/29/23, 3:17 AM Binge eating disorder Pathway As per AACAP 2015 guidelines: Offer outpatient psychosocial interventions as the initial treatment of choice in pediatric and adolescent patients with an eating disorder. B Consider offering psychiatric hospitalization, day programs, partial hospitalization programs, and residential programs for eating disorders in pediatric and adolescent patients only when outpatient interventions have been unsuccessful or are unavailable. C As per AAFP 2015 guidelines, assess medical stability and the need for hospitalization in the initial evaluation of patients with eating disorders. B As per RANZCP 2014 guidelines, consider admitting patients to an inpatient or day program unit if there is an increased risk of non-response to outpatient/community-based care. C Pharmacotherapy, general principles: As per SIGN 2022 guidelines, do not use medications either as an alternative or as an adjunct to psychological treatment in patients with BED. D As per AACAP 2015 guidelines, reserve medications, including complementary and alternative medications, for comorbid conditions and refractory cases. B As per RANZCP 2014 guidelines: Consider offering pharmacotherapy as an adjunctive treatment for an additive benefit. B Offer pharmacological treatment where psychological therapy is not available. A Pharmacotherapy, antidepressants: As per APA 2023 guidelines, offer antidepressants in adult patients with BED preferring medication or not responding to psychotherapy alone. B As per RANZCP 2014 guidelines: Consider offering SSRIs in patients with BED. B Monitor adverse effects of antidepressants and modify use as required. B Pharmacotherapy (stimulants): consider offering lisdexamfetamine in adult patients with BED preferring medication or not responding to psychotherapy alone. C Pharmacotherapy (anticonvulsants): Consider offering topiramate in patients with comorbid obesity. C Monitor adverse effects of antiepileptic agents and modify use as required. B Pharmacotherapy, obesity medications: As per RANZCP 2014 guidelines, consider offering orlistat for weight loss in patients with comorbid obesity. C As per APA 2006 guidelines, consider offering orlistat in addition to a guided self-help CBT program for additional weight reduction. C 4. Nonpharmacologic interventions Psychotherapy: https://web.pathway.md/diseases/recTfpNVEFkYzkUO6 4/6 6/29/23, 3:17 AM Binge eating disorder Pathway As per APA 2023 guidelines, offer eating disorder-focused CBT or interpersonal therapy, in either individual or group formats, in patients with BED. B As per SIGN 2022 guidelines: Consider offering CBT or interpersonal psychotherapy as first-line therapy in adult patients with BED. Consider offering dialectical-based therapy, integrative cognitive-affective therapy, brief strategic therapy, or schema therapy if CBT or interpersonal psychotherapy are ineffective, unsuitable, or unacceptable. C Consider offering dialectical behavior therapy in patients with comorbid substance misuse disorder or emotionally unstable personality disorder. C Consider offering CBT, interpersonal psychotherapy, or family-based interventions in adolescent patients with BED. B As per RANZCP 2014 guidelines, offer individual psychological therapy (therapist-led CBT or enhanced CBT; alternatively, CBT adapted for internet delivery or in guided self-help form) as first-line therapy in adult patients with BED. A Technology-based interventions: As per SIGN 2022 guidelines, consider offering psychological assessments and treatment via videoconferencing as an adjunct or alternative to in-person sessions when there are barriers to accessing in-person sessions. C As per CPG 2021 guidelines, offer internet CBT-based guided self-help and relapse prevention in emerging adult patients with BED. A Show 4 more Yoga: advise practicing, yoga in addition to standard treatments, in medically stable young patients with other specified feeding and eating disorders. B 5. Specific circumstances Pregnant patients: elicit history of current or past history of eating disorders in females during pregnancy and postnatal period, recognizing the potential barriers for disclosure. A Show 13 more Clinical findings Symptoms Past medical history Anxiety Anorexia nervosa Binge eating Bulimia nervosa Body image dissatisfaction Depression Eating unusually large amounts of food Metabolic syndrome Obesity Purging behavior Unable to stop eating https://web.pathway.md/diseases/recTfpNVEFkYzkUO6 5/6 6/29/23, 3:17 AM Binge eating disorder Pathway Social history Dietary restrictions References 1. American Psychiatric Association. Treatment of patients with eating disorders,third edition. American Psychiatric Association. Am J Psychiatry. 2006 Jul;163 7 Suppl):4 54. Open 2. Phillipa Hay, David Chinn, David Forbes et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry. 2014 Nov;48 11 977 1008. Open 3. Catherine Crone, Laura J Fochtmann, Evelyn Attia et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Eating Disorders. Am J Psychiatry. 2023 Feb 1;180 2 167 171. Open 4. Scottish Intercollegiate Guidelines Network. SIGN 164 Eating disorders. SIGN. 2022 Aug. Open 5. Brian C Harrington, Michelle Jimerson, Christina Haxton et al. Initial Evaluation, Diagnosis, and Treatment of Anorexia Nervosa and Bulimia Nervosa. Am Fam Physician. 2015 Jan 1;91 1 46 52. Open 6. US Preventive Services Task Force, Karina W Davidson, Michael J Barry et al. Screening for Eating Disorders in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2022 Mar 15;327 11 1061 1067. Open 7. James Lock, Maria C La Via, American Academy of Child and Adolescent Psychiatry AACAP Committee on Quality Issues CQI . Practice parameter for the assessment and treatment of children and adolescents with eating disorders. J Am Acad Child Adolesc Psychiatry. 2015 May;54 5 412 25. Open 8. Jennifer Couturier, Danielle Pellegrini, Catherine Miller et al. The COVID 19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID 19 and beyond. J Eat Disord. 2021 Apr 16;9 1 46. Open 9. Jennifer Couturier, Leanna Isserlin, Mark Norris et al. Canadian practice guidelines for the treatment of children and adolescents with eating disorders. J Eat Disord. 2020 Feb 1;8 4. Open 10. W Timothy Garvey, Jeffrey I Mechanick, Elise M Brett et al. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY COMPREHENSIVE CLINICAL PRACTICE GUIDELINES FOR MEDICAL CARE OF PATIENTS WITH OBESITY. Endocr Pract. 2016 Jul;22 Suppl 3 1 203. Open 11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision DSM 5 TR ). APA. 2022. Open https://web.pathway.md/diseases/recTfpNVEFkYzkUO6 6/6