We performed a randomized controlled study to test the relative efficacy of guided self-help (gsh) cognitive-behavioral therapy (CBTgsh) and behavioral weight loss treatment (BWLgsh) treatments for binge eating disorder (BED). To provide an additional partial control for non-specific influences of attention, a third control (CON) treatment condition was included. We tested the treatments using a guided self-help approach given the promising results from initial studies using minimal therapist guidance. Ninety consecutive overweight patients (19 males, 71 females) with BED were randomly assigned (5:5:2 ratio) to one of three treatments: CBTgsh (N=37N=37), BWLgsh (N=38N=38), or CON (N=15N=15). The three 12-week treatment conditions were administered individually following guided self-help protocols. Overall, 70 (78%) completed treatments; CBTgsh (87%) and CON (87%) had significantly higher completion rates than BWLgsh (67%). Intent-to-treat analyses revealed that CBTgsh had significantly higher remission rates (46%) than either BWLgsh (18%) or CON (13%). Weight loss was minimal and differed little across treatments. The findings suggest that CBT, administered via guided self-help, demonstrates efficacy for BED, but not for obesity. The findings support CBT administered via guided self-help as a first step in the treatment of BED and provide evidence for its specific effects.
Binge eating disorder (BED) is characterized by recurrent binge eating without the inappropriate compensatory weight control methods found in bulimia nervosa. Binge eating is defined as eating an unusually large amount of food coupled with a subjective sense of loss of control. DSM-IV (APA) research diagnostic criteria also include behavioral indicators to help determine loss of control and require that the binge eating is associated with emotional distress, occurs regularly, and is persistent. Although questions remain regarding the BED diagnosis (Grilo, 1998), it is recognized as a prevalent and important clinical problem (Johnson, Spitzer, & Williams, 2001; NFT, 2000; Wilfley, Wilson, & Agras, 2003) with unanswered questions about treatment (Wilson & Fairburn, 2000).
Patients with BED frequently suffer from multiple problems in addition to binge eating including, high levels of eating disorder psychopathology (unhealthy restraint and eating patterns, eating concerns, and overvalued ideas regarding weight and shape) and psychological distress (depression and low self-esteem) (Johnson et al., 2001; Grilo, Masheb, & Wilson, 2001a). Patients with BED frequently are obese and are therefore at increased risk for morbidity and mortality (NFT, 2000). Ideally, effective treatments for BED would be able to address these multiple problem areas (Goldfein, Devlin, & Spitzer, 2000). Although recent years have witnessed the development of promising treatments for reducing binge eating and associated psychological distress, achieving weight loss in BED patients has been an elusive goal.
Cognitive-behavioral therapy (CBT) has demonstrated efficacy for BED in several controlled studies using different modes of administration (Carter & Fairburn, 1998; Grilo, Masheb, & Wilson, 2005; Wilfley et al., 1993). These studies have documented substantial reductions in binge eating and in most associated problems, except for weight loss, significantly superior to waitlist controls (Carter & Fairburn, 1998; Wilfley et al., 1993) and to fluoxetine (Grilo et al., 2005). Although CBT is regarded as the best-established intervention for BED (NICE, 2004), researchers have raised the question of treatment specificity (Wilson & Fairburn, 2000; Wilfley et al., 2002). One controlled trial reported that individual CBT was significantly superior to pharmacotherapy (Grilo et al., 2005), but one study that utilized a credible psychological comparison treatment failed to observe significant differences between group CBT and group interpersonal psychotherapy (Wilfley et al., 2002).
The association between BED and obesity, and the major health risks associated with obesity, highlight the need for interventions that also reduce weight. It remains unclear whether behavioral weight loss (BWL) has efficacy for weight loss in obese patients with BED (Gladis et al., 1998; Goodrick, Poston, Kimball, Reeves, & Foreyt, 1998). A direct comparison of BWL to CBT would allow a test of treatment specificity and help to answer the clinically important question of whether BWL has efficacy for weight loss in this patient group.
The present study is a randomized controlled trial to test the relative efficacy of CBT and BWL for BED. To control in part for non-specific influences of attention, a third control (CON) treatment condition was added. Given the promising results from studies with bulimia nervosa (Carter et al., 2003; Palmer, Birchall, McGrain, & Sullivan, 2002; Thiels, Schmidt, Treasure, Garthe, & Troop, 1998) and BED (Carter & Fairburn, 1998; Loeb, Wilson, Gilbert, & Labouvie, 2000) using minimal therapist guidance with CBT (Grilo, 2000; Wilson, Vitousek, & Loeb, 2000), treatments were tested using a guided self-help (gsh) approach, and are therefore referred to as CBTgsh and BWLgsh.
