Behavioral Health

Binge-eating disorder: diagnosis and management

Clinical Overview and When to Suspect Binge-Eating Disorder

— Most common eating disorder in the US (lifetime prevalence ~1.2–2.8%), more prevalent than anorexia and bulimia combined

— Female-to-male ratio ~3:2 (much narrower than other eating disorders — men are commonly affected and often missed)

— Peak onset late adolescence to mid-20s; persists into adulthood

— Strong association with obesity (~40–60% of patients with BED have BMI ≥30), but BED can occur at any weight

— Patient presenting for weight management, bariatric evaluation, or "yo-yo dieting" history

— Type 2 diabetes with poor glycemic control and erratic eating patterns

— Depression, anxiety, or PTSD with weight gain or shame about eating

— GERD, IBS-type symptoms, or nocturnal eating

— Hiding food, eating alone, secretive grocery purchases

Definition (DSM-5): Recurrent binge-eating episodes — eating an objectively large amount of food in a discrete period (≤2 hours) with a sense of loss of control — occurring ≥1×/week for ≥3 months, with marked distress and without regular compensatory behaviors (no purging, fasting, or excessive exercise as in bulimia nervosa).

Epidemiology:

When to suspect in ambulatory practice:

Step 3 management: Use a screening tool in primary care — the SCOFF (originally for AN/BN) has limited BED sensitivity; the Binge Eating Disorder Screener-7 (BEDS-7) is preferred. Any positive screen → structured DSM-5 interview.

Severity grading (DSM-5): Mild 1–3 binges/wk, Moderate 4–7, Severe 8–13, Extreme ≥14.

Board pearl: BED is the only eating disorder with an FDA-approved medication — lisdexamfetamine — for moderate-to-severe disease in adults. Anorexia and bulimia have no such FDA-approved-for-the-disorder stimulant; do not confuse.

Key distinction: Loss of control + distress + no compensatory behavior = BED. Add purging/fasting/exercise → bulimia nervosa.

Presentation Patterns and Key History

— Frequency, duration, and triggers of binge episodes (stress, negative affect, restrictive dieting earlier in day)

— Loss of control ("Once I start, I can't stop") — the hallmark subjective feature

— Speed of eating (rapid, until uncomfortably full)

— Eating when not physically hungry; eating alone due to embarrassment

— Feelings afterward: disgust, depression, guilt — but no purging, laxatives, diuretics, or compensatory exercise

— Weight cyclers ("dieter's paradox") — chronic restriction → rebound binge

— Night eating or grazing can coexist but are not diagnostic

— Frequent presentation: requesting weight-loss medication, bariatric surgery referral, or GLP-1 agonist

— Major depressive disorder (most common — up to 50%)

— Anxiety disorders, PTSD, substance use (especially alcohol, stimulants)

— ADHD — shares dopaminergic dysregulation; relevant to lisdexamfetamine response

— Bipolar II — screen before starting stimulants

— Obesity, metabolic syndrome, T2DM, dyslipidemia, HTN, OSA, NAFLD, GERD, osteoarthritis

— Childhood adversity, weight-based teasing, family history of obesity or eating disorders

— Food insecurity paradoxically increases binge risk

Core history elements to elicit (HEADSSS-style but eating-focused):

Associated patterns:

Psychiatric comorbidities (high yield):

Medical comorbidities:

Social/developmental history:

Functional impact: work absenteeism, social withdrawal, intimate-relationship strain — required for "marked distress" criterion.

CCS pearl: When the simulated patient endorses binges, always ask explicitly about purging, laxative use, diuretic misuse, and compensatory exercise — a single "yes" reclassifies the diagnosis to bulimia nervosa and changes pharmacotherapy (SSRI, not stimulant).

Board pearl: Patients with BED often present not complaining of eating — they present for weight, mood, or GI symptoms. The clinician must initiate the conversation; shame keeps it hidden.

Physical Exam Findings (and Hemodynamic Assessment when relevant)

— No pathognomonic findings — this is a clinical/historical diagnosis

— Often elevated BMI, central adiposity, acanthosis nigricans (insulin resistance)

— May appear well-nourished or even overweight — contrast with anorexia (cachexia) and bulimia (often normal BMI with parotid hypertrophy/Russell sign)

— Usually normal hemodynamics — no orthostasis, no bradycardia (unlike anorexia)

— May find HTN, elevated resting HR from metabolic comorbidity

— Check orthostatic vitals if any history of restriction or recent rapid weight loss

— Absence of dental erosion, parotid hypertrophy, or Russell sign (knuckle calluses) — these suggest bulimia, not BED

— If present → reconsider diagnosis or comorbid purging

— Anorexia nervosa → low BMI, bradycardia, hypotension, lanugo, amenorrhea

— Bulimia nervosa → normal/high BMI, dental erosion, Russell sign, parotid hypertrophy, hypokalemic metabolic alkalosis

— BED → normal exam often, with obesity-related findings only

General appearance:

Vital signs:

HEENT:

Cardiopulmonary: screen for OSA stigmata (Mallampati, neck circumference >40 cm), evaluate for HF if longstanding obesity.

Abdomen: hepatomegaly (NAFLD), striae, abdominal obesity (waist circumference ♂>102 cm, ♀>88 cm = metabolic syndrome criterion).

Skin: acanthosis nigricans, intertrigo, stasis dermatitis.

MSK: weight-bearing joint pain, knee crepitus.

Neuro/psych: mood-congruent affect, tearfulness when discussing eating; screen suicidality (PHQ-9 item 9).

Key distinction:

Step 3 management: Document BMI, waist circumference, and BP at every visit — these are your trackable metrics in longitudinal care and trigger guideline-based screening (lipids, A1c, LFTs).

Board pearl: A patient who "binges" but has dental erosion or hypokalemia is bulimic until proven otherwise — the exam reveals the hidden purging.

Diagnostic Workup — Initial Labs and Screening

— CBC, CMP (glucose, electrolytes, BUN/Cr, LFTs, albumin)

— Fasting lipid panel

— Hemoglobin A1c (T2DM prevalence elevated)

— TSH — rule out hypothyroidism contributing to weight; also baseline before stimulant

— Vitamin D, B12 if symptoms

— Urinalysis if concern for diabetes/renal disease

— Normal potassium, normal bicarbonate (purging → hypokalemic, hypochloremic metabolic alkalosis)

— Normal amylase/lipase (chronic vomiting → elevated salivary amylase)

— Baseline rate, rhythm, QTc, evidence of LVH or ischemia

— Screen for personal/family history of sudden cardiac death, structural heart disease, arrhythmia — relative contraindication to stimulants

— PHQ-9 (depression), GAD-7 (anxiety), MDQ or CIDI-3 for bipolar (critical before stimulant), AUDIT-C (alcohol), DAST (drugs), ASRS (adult ADHD)

— Columbia Suicide Severity Rating Scale if PHQ-9 item 9 positive

BED is a clinical, DSM-5 diagnosis — labs are for comorbidity screening and ruling out mimics, not for confirming BED itself.

Baseline labs in every newly diagnosed patient (especially if BMI ≥25):

Pertinent normals that argue against bulimia:

ECG — required before starting stimulants (lisdexamfetamine):

Screen for comorbid psychiatric illness:

Metabolic syndrome workup: waist circumference, BP, fasting glucose, triglycerides, HDL — meets criteria with ≥3.

Step 3 management: In an obese patient with binge eating and elevated A1c, treat BED and T2DM concurrently — uncontrolled binges sabotage glycemic control. Consider GLP-1 agonist (semaglutide/tirzepatide) for weight and glycemia; emerging data also show binge-frequency reduction.

Board pearl: Always check TSH and obtain ECG before lisdexamfetamine — failure to screen cardiac risk is a common testable safety error.

Diagnostic Workup — Advanced and Confirmatory Studies

— Eating Disorder Examination (EDE) — semi-structured interview, considered reference standard

— EDE-Q — self-report version, validated for clinical use

— Questionnaire on Eating and Weight Patterns-5 (QEWP-5) — DSM-5 aligned

— Hyperphagia + weight gain + cognitive change → consider frontotemporal dementia, hypothalamic lesion (craniopharyngioma, post-op), Prader-Willi (pediatric/genetic) → brain MRI

— Polyphagia + polyuria/polydipsia → check glucose (uncontrolled DM mimics binge pattern)

— Hyperphagia + somnolence + hypogonadism → Kleine-Levin syndrome (episodic)

— Nocturnal eating with amnesia → sleep-related eating disorder (parasomnia, often zolpidem-induced) → polysomnography

— Multidisciplinary psychological assessment mandatory

— Active untreated BED is a relative contraindication — treat first, then re-evaluate

— Post-bariatric patients may develop "loss-of-control eating" (smaller volumes due to anatomy but same loss of control) — still clinically significant

Structured diagnostic interviews (gold standard for research/specialty referral):

Differential workup when atypical features present:

Imaging: not routine. Obtain only if neurologic findings, headache, visual changes, or atypical onset (e.g., new-onset binge in older adult).

Bariatric pre-op evaluation:

Sleep study if OSA symptoms (loud snoring, witnessed apnea, Epworth >10).

DEXA if longstanding restriction history or premenopausal amenorrhea (assess for low bone density).

Key distinction: Night-eating syndrome = ≥25% of daily intake after evening meal and/or nocturnal awakenings to eat, with awareness. Sleep-related eating disorder = eating during partial arousal without awareness. BED binges occur awake and are not time-locked to night.

Step 3 management: Before bariatric surgery, obtain psychiatric clearance documenting BED status. CCS pearl: Advance simulated clock 8–12 weeks after starting BED treatment before scheduling sleeve gastrectomy/RYGB consult.

Risk Stratification and First-Line Management Logic

— Mild (1–3 binges/wk): CBT-based psychotherapy alone is first-line

— Moderate-to-severe (≥4/wk) or psychotherapy non-response: add pharmacotherapy

— Extreme severity + medical instability + suicidality: consider higher level of care (PHP, residential)

— Cognitive Behavioral Therapy–Enhanced (CBT-E) — 20 sessions, addresses overvaluation of shape/weight, dietary restraint, mood triggers

— Interpersonal Therapy (IPT) — equivalent long-term efficacy

— Dialectical Behavior Therapy (DBT) — emotion-regulation focus, useful with affect dysregulation

— Guided self-help CBT (CBTgsh) — appropriate for mild cases, primary care–deliverable

— Lisdexamfetamine — only FDA-approved agent for moderate/severe BED

— Topiramate — off-label, evidence-based

— SSRIs — modest binge reduction, best when comorbid depression/anxiety

— Address only after binge stability or concurrently with caution

— Aggressive caloric restriction can worsen binges; favor non-restrictive intuitive-eating + medical weight-loss agents

— GLP-1 agonists (semaglutide, tirzepatide) show emerging benefit for both weight and binge frequency

— Reduction in binge frequency (primary)

— Improvement in mood, function, quality of life

— Stabilization of weight; metabolic comorbidity control

Severity-based treatment matching (DSM-5 + practice guidelines):

First-line psychotherapy (strongest evidence):

Pharmacotherapy options (covered in detail in chunk 7):

Weight management — separate but parallel goal:

Goals of treatment (track at each visit):

Step 3 management: First-line for newly diagnosed mild BED in outpatient = CBT referral + lifestyle counseling; do not start a stimulant on day one. Reserve pharmacotherapy for moderate/severe or inadequate response after 8–12 weeks of CBT.

Board pearl: Combination CBT + medication > either alone for moderate-to-severe disease — most testable answer when both are offered.

Pharmacotherapy — First-Line Drug Regimen

— Prodrug of dextroamphetamine; less abuse liability than IR amphetamines

— Start 30 mg PO qAM, titrate weekly by 20 mg to target 50–70 mg/day (max 70 mg)

— Reduces binge days/week and achieves 4-week binge abstinence in ~40%

— Contraindications: known structural cardiac disease, symptomatic CVD, moderate-severe HTN, hyperthyroidism, MAOI use (within 14 days), advanced arteriosclerosis, glaucoma, history of stimulant abuse

— Cautions: bipolar disorder (mania risk), psychosis, seizure disorder, pregnancy (Category C — avoid)

— Monitor: BP, HR at each visit; weight (expected modest loss); sleep; appetite; mood; signs of misuse/diversion

— Schedule II controlled substance — PDMP check, one prescriber, urine drug screen at baseline

— Reduces binges and produces weight loss

— Start 25 mg qHS, titrate by 25–50 mg weekly to 100–400 mg/day divided BID

— AEs: paresthesias, cognitive slowing ("dopamax"), kidney stones, metabolic acidosis, teratogenic (cleft palate) — counsel contraception

— Useful when stimulant contraindicated or comorbid migraine

— Modest binge reduction; best choice if comorbid MDD or anxiety

— Fluoxetine 60 mg is FDA-approved for bulimia (not BED) — frequent distractor

— Bupropion — helpful if depression + desire for weight loss; contraindicated if active purging or seizure history (BED ok if no purging)

— GLP-1 agonists — semaglutide/tirzepatide emerging data

Lisdexamfetamine dimesylate (Vyvanse) — only FDA-approved drug for moderate-to-severe BED in adults:

Topiramate — strongest off-label evidence:

SSRIs (fluoxetine, sertraline, citalopram):

Other options:

Board pearl: Lisdexamfetamine = BED. Fluoxetine 60 mg = bulimia nervosa. No FDA-approved drug for anorexia nervosa (olanzapine has off-label evidence for weight restoration). Memorize this triad.

Step 3 management: Before prescribing lisdexamfetamine — screen bipolar, check ECG, document BP/HR, review PDMP, counsel on controlled-substance terms.

Expanded Pharmacology and Combined Treatment Strategies

— Step 1: Lisdexamfetamine OR topiramate (patient preference, comorbidity-driven)

— Step 2: If partial response at 8–12 weeks → optimize dose, ensure CBT engagement

— Step 3: Switch class or augment (e.g., lisdexamfetamine + SSRI for residual depression)

— Step 4: Refer to eating-disorder specialist; consider PHP

— + ADHD → lisdexamfetamine (treats both)

— + Migraine, seizure d/o (controlled), or want weight loss → topiramate

— + MDD/anxiety → SSRI (fluoxetine, sertraline) ± lisdexamfetamine

— + T2DM/obesity → add semaglutide or tirzepatide

— + Bipolar disorder → avoid stimulants/bupropion; use topiramate or lamotrigine-augmented mood stabilizer + CBT

— + Substance use disorder (stimulant/cocaine) → avoid lisdexamfetamine; topiramate preferred

— Lisdexamfetamine + MAOI → hypertensive crisis (14-day washout)

— Lisdexamfetamine + serotonergic agents → serotonin syndrome (monitor)

— Topiramate + OCPs → reduced contraceptive efficacy at doses >200 mg → counsel barrier method or IUD

— Topiramate + metformin → ↑ metabolic acidosis risk

— Weeks 1, 2, 4, 8, 12 then quarterly

— Each visit: binge diary, BP/HR, weight, mood, suicidality, side effects, controlled-substance compliance

— Annual: ECG if cardiac risk, CMP, A1c, lipids

Stepwise pharmacologic algorithm:

Choosing by comorbidity (high yield):

Drug interactions to flag:

Monitoring schedule:

Duration: continue effective pharmacotherapy ≥6–12 months after binge remission; relapse common on discontinuation — taper slowly with CBT booster sessions.

CCS pearl: On the simulated case, after starting lisdexamfetamine, advance clock 4 weeks, recheck BP/HR, binge frequency, weight, and PHQ-9 — these are the trackable monitoring orders graders expect.

Board pearl: Stimulant + CBT > stimulant alone; relapse rate ~50% within 12 months of stopping medication — always pair pharmacotherapy with psychotherapy.

Special Populations — Elderly and Renal/Hepatic Impairment

— BED prevalence declines but remains underdiagnosed; late-onset cases often follow bereavement, depression, or retirement transition

— Differential expands: new hyperphagia → screen for frontotemporal dementia (behavioral variant), hypothalamic mass, medication effect (corticosteroids, mirtazapine, olanzapine, gabapentin)

— CBT remains first-line; modify for cognitive pace

— Lisdexamfetamine cautions in elderly:

· Cardiovascular risk amplified → mandatory ECG, BP monitoring; consider stress test if angina/risk factors

· Start lower (20–30 mg), titrate slowly

· Avoid if uncontrolled HTN, recent MI, arrhythmia, CHF, CAD

— Topiramate cautions: confusion, falls, hyponatremia, dehydration → start 12.5–25 mg qHS

— SSRI cautions: hyponatremia (SIADH), QT prolongation (citalopram dose cap 20 mg in age >60), GI bleed risk with NSAIDs/anticoagulants

— Lisdexamfetamine: reduce max dose in severe CKD — eGFR 15–29: max 50 mg/day; ESRD on HD: max 30 mg/day; not dialyzable

— Topiramate: renally cleared — reduce dose by 50% if CrCl <70; increased nephrolithiasis risk → ↑ hydration

— SSRIs: generally safe; sertraline preferred in CKD

— Lisdexamfetamine: no specific dose adjustment but use caution

— Topiramate: caution; minor hepatic metabolism

— Avoid bupropion in severe cirrhosis (↑ seizure risk)

Older adults (≥65 yr):

Renal impairment:

Hepatic impairment:

Polypharmacy review: deprescribe weight-promoting/appetite-stimulating agents when feasible — mirtazapine, olanzapine, quetiapine, gabapentin, pregabalin, corticosteroids, insulin (excess), sulfonylureas.

Step 3 management: For an older patient with new-onset binge eating + executive dysfunction + disinhibition → order brain MRI before assuming primary BED — bvFTD can present this way.

Board pearl: Citalopram max dose 20 mg/day in age >60 due to QT prolongation — common Step 3 trap when an older BED patient with depression is started on an SSRI.

Special Populations — Pregnancy, Adolescents, and Other Subgroups

— BED often improves during pregnancy but may rebound postpartum (postpartum depression doubles relapse risk)

— Pharmacotherapy:

· Lisdexamfetamine — avoid (amphetamines associated with low birth weight, preterm birth, neonatal withdrawal); discontinue pre-conception

· Topiramate — avoid (cleft lip/palate, oral cleft risk ×2–3 in first trimester); counsel reliable contraception in reproductive-age women

· SSRIs generally compatible (sertraline preferred in lactation); fluoxetine has longer half-life and more transfer

· Bupropion acceptable if benefits outweigh risks

— CBT and IPT are first-line during pregnancy — safest, effective

— Screen for hyperemesis gravidarum vs. covert purging — overlapping symptoms

— Postpartum: monitor closely; coordinate with OB and pediatrics for feeding/weight concerns

— BED can be diagnosed in adolescents (DSM-5 same criteria)

— Family-Based Therapy (FBT) adapted for BED; CBT-A also effective

— Lisdexamfetamine NOT FDA-approved for BED in <18 (it is approved for ADHD ≥6 yr) — off-label for adolescent BED

— Screen for bullying, weight-based teasing, social media body-image exposure

— Treat BED before surgery; uncontrolled BED → poorer weight loss and post-op "grazing"

— Post-op patients can develop loss-of-control eating despite anatomic restriction — assess at every follow-up

— Binge–restrict cycles common; assess in context of weight-class sports

— Higher prevalence; integrate gender-affirming, weight-neutral approach

— Reduced binge frequency reported; monitor for restrictive patterns emerging as appetite suppresses

Pregnancy and lactation:

Adolescents:

Bariatric surgery candidates:

Athletes and military:

LGBTQ+ patients:

Patients on GLP-1 agonists:

Step 3 management: A reproductive-age woman started on topiramate must receive contraception counseling — preferably IUD or non-OCP method given enzyme interaction at doses >200 mg.

Board pearl: Topiramate + pregnancy = cleft palate. Document contraception discussion in the chart.

Complications and Adverse Outcomes

— Metabolic: T2DM, metabolic syndrome, dyslipidemia, NAFLD/NASH, hyperuricemia/gout

— Cardiovascular: HTN, CAD, HFpEF, atrial fibrillation, stroke

— Pulmonary: OSA, obesity hypoventilation syndrome, asthma

— GI: GERD, cholelithiasis, NAFLD progressing to cirrhosis/HCC

— MSK: osteoarthritis (knees, hips), low back pain

— Endocrine/repro: PCOS, infertility, hypogonadism (men), menstrual irregularity

— Cancer risk: elevated for endometrial, breast (postmenopausal), colorectal, esophageal adenocarcinoma, pancreatic, kidney, liver

— Acute: gastric dilation/rupture rare but reported after massive binge — surgical emergency

— Worsening depression, anxiety, PTSD

— Suicidality — BED carries elevated suicide risk independent of BMI; screen at every visit

— Substance use — alcohol, stimulants (often self-medication of binges)

— Social isolation, occupational impairment

— Lower HRQoL than equally obese non-BED controls

— Increased healthcare utilization and absenteeism

— Lisdexamfetamine: HTN, tachycardia, insomnia, decreased appetite, dependence, diversion, psychosis at high doses, sudden cardiac death (rare; structural disease)

— Topiramate: nephrolithiasis, metabolic acidosis, paresthesias, cognitive dulling, acute angle-closure glaucoma, oligohidrosis/hyperthermia

— SSRI: sexual dysfunction, weight gain (paroxetine worst), GI upset, hyponatremia

— Inadequate weight loss, weight regain, anastomotic ulcers from chronic overeating, alcohol use disorder (especially post-RYGB)

Medical complications (driven mostly by obesity comorbidity):

Psychiatric complications:

Quality of life and economic burden:

Treatment-related complications:

Bariatric post-op complications in undiagnosed BED:

Step 3 management: At each follow-up, document BP, HR, weight, mood, suicide screen, and substance use — these are the trackable safety parameters that justify continued therapy.

Board pearl: Sudden severe abdominal pain + distention after a large binge → gastric dilation/rupture → upright CXR, NG decompression, emergent surgery.

When to Escalate Care — Inpatient and Specialty Triage

— Active suicidality (plan, intent, recent attempt) → psychiatric emergency department / inpatient psych

— Severe psychiatric comorbidity (psychosis, mania, severe MDD with functional collapse)

— Substance use disorder requiring detox

— Medical instability from complications (DKA in comorbid T2DM, acute coronary syndrome, gastric rupture, severe electrolyte derangement suggesting hidden purging)

— Failure of outpatient treatment (≥2 adequate trials of psychotherapy + pharmacotherapy without response)

— Outpatient (OP): weekly therapy + medication management

— Intensive outpatient (IOP): 3 hrs/day, 3 days/week

— Partial hospitalization (PHP): 6 hrs/day, 5 days/week — most appropriate step for treatment-resistant BED with significant functional impairment

— Residential: 24-hour, non-medical — for severe psychiatric comorbidity or relapsing illness

— Inpatient psychiatric: suicidality, acute decompensation

— Inpatient medical: medical complications

— Psychiatry — for medication management, dual diagnosis, severity

— Registered dietitian with eating-disorder training — meal planning, intuitive eating

— Endocrinology — for refractory T2DM or obesity management

— Bariatric surgery — only after BED treated/stabilized

— Sleep medicine — OSA

— Cardiology — pre-stimulant clearance if abnormal ECG or risk factors

Outpatient management is appropriate for the majority — BED rarely requires hospitalization for the eating disorder itself. Escalate when:

Levels of care (eating-disorder continuum):

Consultations to obtain:

CCS pearl: A BED patient with PHQ-9 = 22, item 9 positive ("thoughts of suicide nearly every day"), and a plan → order 1:1 sitter, psychiatry consult STAT, remove access to means, consider involuntary hold if refusing voluntary admission.

Step 3 management: Escalation decisions hinge on safety (suicidality), function (work/school collapse), and prior treatment failure — not on binge frequency alone.

Board pearl: BED itself rarely warrants admission; comorbidity drives escalation.

Key Differentials — Within Eating and Feeding Disorders

— Binges + recurrent compensatory behaviors (vomiting, laxatives, diuretics, fasting, excessive exercise) ≥1×/wk for 3 months

— Exam: parotid hypertrophy, dental erosion, Russell sign, hypokalemia, metabolic alkalosis

— Tx: CBT-E first-line + fluoxetine 60 mg (only FDA-approved drug for BN)

— Bupropion contraindicated (seizure risk with purging-induced electrolyte changes)

— Restriction + binges/purges but at low body weight (BMI <18.5 or significant percentile drop)

— Bradycardia, hypotension, hypothermia, amenorrhea

— Tx: weight restoration first; olanzapine has modest evidence

— All criteria for AN met except weight is normal/high — important in patients who lost significant weight from elevated BMI

— Still medically dangerous despite "normal" weight

— Binge eating of low frequency/duration (< criteria for BED) — same treatment principles

— Purging disorder, night-eating syndrome included here

— Restriction based on sensory aversion, fear of choking, or lack of interest — no body-image disturbance, no binges

— Pediatric/adolescent predominance

— Distinct DSM-5 entities; not confused with BED clinically but appear on stems

— ≥25% intake after evening meal and/or ≥2 nocturnal awakenings to eat per week, with awareness

— Often comorbid with BED but distinct; treat with SSRI (sertraline best evidence) ± CBT

— Parasomnia — eating during partial arousal without awareness; associated with zolpidem, restless legs, sleepwalking → polysomnography, discontinue offending agent

— Binges + purging + normal weight → bulimia nervosa

— Binges + purging + low weight → anorexia, binge/purge subtype

— Binges + NO purging + any weight → binge-eating disorder

Bulimia nervosa (BN):

Anorexia nervosa, binge-eating/purging subtype:

Atypical anorexia nervosa:

Other specified feeding/eating disorder (OSFED):

Avoidant/restrictive food intake disorder (ARFID):

Pica and rumination disorder:

Night-eating syndrome (NES):

Sleep-related eating disorder (SRED):

Key distinction (high-yield triad):

Board pearl: The single best discriminator between BED and BN is the presence of recurrent compensatory behavior — ask explicitly every time.

Key Differentials — Non-Eating-Disorder Mimics

— Uncontrolled diabetes mellitus — polyphagia + polyuria + polydipsia + weight loss despite eating → check glucose/A1c

— Hyperthyroidism — increased appetite + weight loss + tachycardia → TSH

— Hypothyroidism — weight gain without true hyperphagia (slowed metabolism) — distractor

— Cushing syndrome — central obesity, striae, proximal weakness, HTN, hyperglycemia

— Hypoglycemia (insulinoma, post-bariatric) — reactive eating to relieve symptoms

— Hypothalamic lesions (craniopharyngioma, sarcoidosis, post-surgical, radiation) → hyperphagic obesity, hormonal dysfunction

— Klüver-Bucy syndrome — bilateral temporal lobe damage → hyperorality, hypersexuality, placidity

— Frontotemporal dementia (behavioral variant) — disinhibition, hyperphagia (sweet preference), apathy, executive dysfunction

— Kleine-Levin syndrome — episodic hypersomnia + hyperphagia + hypersexuality in adolescent males

— Prader-Willi syndrome — infantile hypotonia, insatiable hyperphagia, intellectual disability, hypogonadism, almond eyes

— Antipsychotics — olanzapine, clozapine, quetiapine (high); risperidone (moderate); aripiprazole/ziprasidone (low)

— Antidepressants — mirtazapine, paroxetine, TCAs

— Mood stabilizers — valproate, lithium, gabapentin, pregabalin

— Corticosteroids, insulin, sulfonylureas, antihistamines

— Cannabis — "the munchies"

— Atypical depression — mood reactivity, hyperphagia, hypersomnia, leaden paralysis — overlaps with BED

— Bipolar disorder — manic/hypomanic episodes with disinhibited eating

— Borderline personality disorder — impulsive eating among other impulsive behaviors

— PTSD — emotional eating as numbing/avoidance

— Substance use — cannabis-induced, post-stimulant binges

Endocrine and metabolic causes of hyperphagia:

Neurologic and structural causes:

Medication-induced hyperphagia/weight gain:

Psychiatric mimics:

Step 3 management: New-onset hyperphagia in an adult — order glucose, A1c, TSH, medication review, focused neuro exam before diagnosing primary BED; image brain if neurologic signs present.

Board pearl: Klüver-Bucy = hyperorality + hypersexuality + placidity; Kleine-Levin = episodic somnolence + hyperphagia + young male; bvFTD = sweet preference + disinhibition + executive dysfunction.

Secondary Prevention, Discharge Plan, and Long-Term Strategy

— Continue effective pharmacotherapy 6–12 months minimum post-remission; many require longer

— Maintain monthly to quarterly CBT booster sessions for the first year

— Identify and rehearse responses to personal triggers (stress, restrictive dieting, social events, holidays, weighing rituals)

— Establish regular meal pattern (3 meals + 2 snacks) — irregular eating predicts relapse

— Avoid aggressive caloric restriction in early recovery — paradoxically reinforces binges

— Emphasize mindful eating, intuitive eating, body acceptance

— Modest activity goal: 150 min/week moderate aerobic + 2 days resistance training (NOT compensatory)

— Sleep hygiene: 7–9 hr; treat OSA

— Limit alcohol (disinhibits binges, calories)

— Diabetes: A1c target individualized; GLP-1 agonist or metformin first-line; avoid sulfonylureas (weight gain, hypoglycemia–binge cycle)

— Hypertension: lifestyle + ACEi/ARB or thiazide; avoid sympathomimetic spike if on lisdexamfetamine

— Dyslipidemia: statin per ASCVD risk; lifestyle

— Depression/anxiety: continue SSRI; psychotherapy maintenance

— OSA: CPAP adherence

— Lisdexamfetamine: continue same effective dose; do not dose-escalate beyond 70 mg; periodic drug holidays not recommended

— Topiramate: maintain effective dose; annual eye exam for angle-closure risk

— SSRI: continue ≥6–12 months past mood remission

— Annual influenza, pneumococcal per age/comorbidity, COVID boosters, Tdap

— Age-appropriate cancer screening (colon, breast, cervical) — obesity ↑ risk

— Dental care, ophthalmologic exam (topiramate, diabetes)

Relapse-prevention framework after binge remission:

Lifestyle and weight-management plan:

Comorbidity optimization:

Pharmacotherapy maintenance specifics:

Vaccinations and preventive care (USPSTF-aligned):

Step 3 management: Discharge from PHP/IOP → schedule outpatient psychiatry within 7 days, therapy within 7 days, PCP within 2–4 weeks — close transitions prevent relapse and ED rebound.

Board pearl: Premature discontinuation of effective pharmacotherapy → ~50% relapse within 12 months — patient education on this is part of informed consent.

Follow-Up, Monitoring, and Rehabilitation/Counseling

— Initial titration: weeks 1, 2, 4, 8, 12

— Maintenance: every 3 months

— Stable on therapy 1+ year: every 6 months

— Therapist: weekly during active CBT-E (16–20 sessions), then taper to monthly boosters

— Binge diary review: frequency, triggers, loss-of-control episodes

— Vitals: BP, HR (especially on stimulant), weight, BMI, waist circumference

— Mood/safety: PHQ-9, GAD-7, suicide screen

— Substance use: AUDIT-C, urine drug screen (if on controlled substance)

— Side effects specific to medication

— Adherence — pill count, PDMP review

— Functional status: work, school, relationships

— A1c, fasting lipids, CMP annually (or per comorbidity)

— TSH annually if on stimulant or symptomatic

— ECG if cardiac symptoms emerge or new risk factors

— Urine pregnancy before topiramate refill in reproductive-age women

— Self-monitoring of food intake and emotions

— Cognitive restructuring of weight/shape overvaluation

— Behavioral experiments challenging dietary rules

— Stimulus control and urge surfing

— Relapse-prevention plan in writing

— PCP, psychiatrist, therapist, RD with ED training, social worker; involve family with patient permission

— Binges/week, % weeks abstinent, PHQ-9 trajectory, BMI, A1c, BP

Follow-up cadence (outpatient ambulatory):

Each visit — structured checklist:

Laboratory monitoring:

Psychotherapy components reinforced over time:

Multidisciplinary team:

Patient resources: NEDA (National Eating Disorders Association), ANAD helpline, self-help workbooks (Fairburn's Overcoming Binge Eating)

Outcome metrics to track in EHR registry:

CCS pearl: On the simulation, after starting CBT + lisdexamfetamine, advance clock 4 weeks and order: BP, HR, weight, PHQ-9, binge diary review. These five orders demonstrate appropriate longitudinal monitoring.

Board pearl: Use shared decision-making and motivational interviewing to address ambivalence — common in BED given shame and prior failed diets.

Ethical, Legal, and Patient Safety Considerations

— Avoid weight-centric language; use person-first ("patient with obesity," "patient who experiences binges")

— Weight-bias from clinicians worsens outcomes, increases avoidance of care

— Document non-judgmental counseling

— Discuss abuse/dependence/diversion risk, cardiovascular risk including rare sudden cardiac death, controlled-substance agreement (single prescriber, single pharmacy, no early refills, PDMP checks, urine drug screens)

— Document specifically the structural heart disease screen and family history of sudden cardiac death

— Teratogenicity (cleft palate) — document contraception counseling in reproductive-age patients

— Cognitive side effects may impair driving/work

— In adolescents, balance autonomy and parental involvement per state minor-consent laws

— Most states allow confidential mental health treatment for older adolescents; eating-disorder-specific carve-outs vary

— Suspected child or elder abuse/neglect — mandatory in all states

— Tarasoff-style duty to warn if patient discloses intent to harm an identifiable third party

— BED patients with active suicidality lacking capacity may require involuntary psychiatric hold under state law (e.g., 5150 in CA, 9.39 in NY)

— Discharge from PHP/IOP/inpatient to outpatient is a peak-relapse window

— Step 3 mandate: schedule outpatient psychiatry within 7 days, therapy within 7 days, PCP within 2–4 weeks; medication reconciliation at every transition; send a closed-loop note to receiving clinicians

— Active untreated BED → patient may lack capacity to consent until psychiatric stabilization

— Document treatment of BED before surgical clearance

— Counsel about stimulant-related insomnia/jitteriness; topiramate cognitive effects

Stigma and weight bias:

Informed consent for controlled substances (lisdexamfetamine):

Informed consent for topiramate:

Confidentiality and adolescents:

Mandatory reporting:

Capacity and involuntary hold:

Transitions of care — high-risk handoff:

Bariatric surgery ethics:

Driving safety:

Step 3 management: Before starting lisdexamfetamine, document: (1) ECG result, (2) cardiac history screen, (3) PDMP review, (4) controlled-substance agreement signed, (5) bipolar/psychosis screen, (6) baseline BP/HR.

Board pearl: Missing the structural heart disease screen before a stimulant is the most testable safety lapse — and a malpractice red flag in real practice.

High-Yield Associations and Rapid-Fire Clinical Facts

BED epidemiology: most common ED in the US; ♀:♂ ~3:2 (narrower than AN/BN); lifetime prevalence ~1–3%.

DSM-5 minimum: binges ≥1/week for ≥3 months + ≥3 of 5 features (rapid, until full, when not hungry, alone, guilt) + distress + no compensation.

Only FDA-approved drug for BED: lisdexamfetamine (50–70 mg/day, adults, moderate–severe).

Only FDA-approved drug for bulimia nervosa: fluoxetine 60 mg/day.

No FDA-approved drug for anorexia nervosa; olanzapine has off-label evidence for weight restoration.

First-line psychotherapy: CBT-E (Fairburn); IPT and DBT also effective.

Best off-label medication: topiramate — also reduces weight; watch for cleft palate, kidney stones, paresthesias, glaucoma.

Cardiac safety: baseline ECG, BP, HR, structural-heart-disease history before stimulant.

Topiramate + OCPs: reduced contraceptive efficacy at doses >200 mg → IUD/barrier.

Citalopram cap in age >60: 20 mg/day (QT).

Bupropion: safe in BED without purging; contraindicated in active BN/AN due to seizure risk from electrolyte disturbance.

GLP-1 agonists (semaglutide, tirzepatide): emerging benefit for binges + weight + glycemia.

Bariatric surgery: treat BED first; post-op "loss-of-control eating" remains a risk.

Comorbidities: MDD (#1), anxiety, PTSD, ADHD, substance use, T2DM, metabolic syndrome, OSA, NAFLD.

Acute complication of massive binge: gastric dilation/rupture — emergent surgery.

Differentials: BN (purging), AN binge/purge subtype (low weight), night-eating syndrome (≥25% after dinner, awake), sleep-related eating disorder (parasomnia, amnesia, zolpidem).

Neuropsychiatric mimics: bvFTD (sweet preference, disinhibition), Kleine-Levin (young male, episodic), Klüver-Bucy (bitemporal injury, hyperorality), Prader-Willi (pediatric, insatiable).

Endocrine mimics: uncontrolled DM, hyperthyroidism, Cushing, hypothalamic lesion.

Combination therapy (CBT + medication) > either alone for moderate–severe BED.

Relapse rate ~50% within 12 months of stopping effective pharmacotherapy.

Board pearl: Pair every BED diagnosis with a PHQ-9 and suicide screen — comorbid MDD is the rule, not exception.

Board Question Stem Patterns

— 32-year-old woman with BMI 36, eats large quantities of food rapidly when stressed, feels out of control, eats alone, denies vomiting/laxatives/exercise, 3 episodes per week for 6 months. PHQ-9 = 14.

— Best initial step: refer for CBT (mild–moderate); if moderate–severe or comorbid MDD prominent → CBT + lisdexamfetamine or SSRI.

— Patient binges then runs 5 miles to "burn it off" afterward → bulimia nervosa, not BED → CBT-E + fluoxetine 60 mg.

— BED patient about to start lisdexamfetamine; family history of sudden cardiac death at age 35.

— Next step: ECG and cardiology evaluation before initiation; consider topiramate or SSRI instead.

— 28-year-old on topiramate 200 mg for BED, taking OCPs. Presents asking about pregnancy planning.

— Counsel: topiramate is teratogenic (cleft palate); switch to safer agent (SSRI) or use non-OCP contraception (IUD); plan pre-conception switch.

— Patient seeking sleeve gastrectomy, BMI 44, binges 5×/week.

— Best step: defer surgery; treat BED first with CBT ± lisdexamfetamine, reassess in 3–6 months.

— 68-year-old man with new hyperphagia (sweet preference), apathy, socially inappropriate behavior → bvFTD → brain MRI, neurology.

— Adolescent boy with episodic 10-day spells of hypersomnia + hyperphagia + hypersexuality → Kleine-Levin syndrome.

— Patient eats at night without memory; takes zolpidem → sleep-related eating disorder → stop zolpidem, PSG.

— Patient with BED + adult ADHD → lisdexamfetamine (treats both).

— BED patient PHQ-9 = 23, plan present → psychiatric admission, 1:1 observation, remove means.

— Patient on olanzapine for schizophrenia developed binges and 30-lb weight gain.

— Next step: switch to weight-neutral antipsychotic (aripiprazole, lurasidone, ziprasidone) + behavioral intervention.

Stem 1 — Classic BED:

Stem 2 — Distinguishing BED from bulimia:

Stem 3 — Stimulant safety:

Stem 4 — Reproductive-age woman on topiramate:

Stem 5 — Bariatric clearance:

Stem 6 — Mimics:

Stem 7 — Comorbid ADHD:

Stem 8 — Suicidality:

Stem 9 — Patient on antipsychotic with weight gain and binges:

CCS pearl: Expect to be asked to order ECG, PHQ-9, BMP, A1c, lipids, urine pregnancy as part of safe initiation of pharmacotherapy.

Board pearl: When BN and BED both fit, the presence of even one purging behavior shifts the diagnosis to BN — the test rewards the student who explicitly asks about compensation.

One-Line Recap

Binge-eating disorder is recurrent loss-of-control binges (≥1/week for ≥3 months) without compensatory behaviors, best treated with CBT-E first-line and lisdexamfetamine (or topiramate) for moderate-to-severe disease, alongside aggressive management of comorbid depression, obesity, and metabolic disease.

Diagnosis: DSM-5 clinical — binges + loss of control + 3 of 5 features + distress + NO compensation. Distinguish from bulimia (purging), anorexia binge/purge subtype (low weight), night-eating syndrome (awake, post-dinner), and sleep-related eating disorder (amnestic, zolpidem-linked).

Treatment: CBT-E is first-line; add lisdexamfetamine 50–70 mg/day (only FDA-approved drug for BED) or topiramate for moderate–severe disease. Pair with comorbidity care (MDD, T2DM, OSA). Combination therapy > monotherapy.

Safety: Pre-stimulant workup = ECG, BP, structural heart disease and family sudden-death screen, bipolar screen, PDMP, controlled-substance agreement. Topiramate = teratogen (cleft palate) → contraception counseling. Always screen suicidality (PHQ-9).

Step 3 management: Treat BED before bariatric surgery; schedule outpatient follow-up within 7 days of any higher-level-of-care discharge; continue effective pharmacotherapy 6–12+ months post-remission with CBT boosters to mitigate the ~50% one-year relapse rate.

Board pearl: Memorize the FDA triad — lisdexamfetamine for BED, fluoxetine 60 mg for bulimia, nothing approved for anorexia (olanzapine off-label). This single fact answers a disproportionate share of eating-disorder pharmacotherapy questions on Step 3.