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Letter to the Editor

Severity of Binge-Eating Disorder and Its Effects on Treatment Outcome

Antonios Dakanalis, MD, PsyD, PhD, and Massimo Clerici, MD, PhD

Published: August 23, 2017

See reply by Grilo and article by Grilo

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

Severity of Binge-Eating Disorder and Its Effects on Treatment Outcome

To the Editor: A valuable overview by Carlos Grilo1 published in a recent supplement to the Journal provides an important update on the psychological and behavioral treatments of binge-eating disorder (BED), reviewing also the evidence about predictors of treatment outcome. This overview can possibly be complemented by recent evidence on the severity of BED, as defined by the DSM-5,2 and its impact on treatment outcome.

BED, like other eating disorders, is characterized by substantial within-diagnosis heterogeneity such that different individuals with the same disorder may exhibit variation in terms of symptom severity, underscoring the need for reliable indicators of disease severity.3,4 Importantly, the DSM-5 introduced a new severity specifier for BED,2 whose reliability, validity, and clinical significance have been recently established,3 to address within-group heterogeneity and variability in severity of the disorder and assist clinicians in tracking patients’ progress. Specifically, 4 BED severity groups based on the weekly frequency of binge-eating (BE) episodes were defined in the DSM-52 as follows: mild, 1-3 episodes/ week; moderate, 4-7 episodes/wk; severe, 8-13 episodes/wk; and extreme, > 14 episodes/wk.

In his overview of psychological and behavioral treatments for people with BED, Grilo1 suggested therapist-led cognitive-behavioral therapy (CBT) as the best-supported treatment option. The recent meta-analytic5 evidence that more participants achieved abstinence from BE with therapist-led CBT versus waiting list (58.8% vs 11.2%) is in favor of CBT. However, and despite empirical evidence providing partial support of the theoretical model on which CBT is based,6 the absence of attention to durability of effects7 is among several factors requiring consideration when interpreting Grilo’s 1 assertions. Further, the aforementioned meta-analytic5 finding highlights that although CBT is regarded by Grilo1 as the treatment of choice for BED, a substantial proportion of patients do not achieve BE abstinence. This picture represents only a general tendency if further refined by just-published research3 that contributes to gaining insight into the severity-dependent response to CBT. Specifically, significant differences were observed in abstinence from BE (treatment outcome) achieved by 6.7%, 38.7%, 66.7%, and 98.5% of adults who were classified with DSM-5 extreme, severe, moderate, and mild severity of BED2 (see above) based on their pretreatment clinician-rated (weekly) frequency of BE episodes.3 While, according to Grilo,1 the overvaluation of shape and weight signals greater severity, factors external to eating disorder features addressed in CBT,6 such as deficits in coping with aversive emotional states and psychiatric-disorder comorbidity, have recently emerged as the most relevant variables distinguishing the DSM-5-defined severity groups of BED that, as noted, showed a differential treatment outcome.3 These findings are relevant also because the existing/alternative severity approaches for BED, such as subtyping based on overvaluation of shape and weight, were not predictive of BE remission.8

Two questions arising from the above and needing consideration in future treatment research for BED are whether (a) second-level treatment would be effective for those in whom first-level (eg, CBT)1 treatment fails and (b) psychological/behavioral1 and pharmacologic9 interventions should be combined to promote more appropriate treatment for severe-to-extreme BED, since this should differ from treatment regimens for mild-to-moderate presentations.3,10


1. Grilo CM. Psychological and behavioral treatments for binge-eating disorder. J Clin Psychiatry. 2017;78(suppl 1):20-24. PubMed doi:10.4088/JCP.sh16003su1c.04

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

3. Dakanalis A, Colmegna F, Riva G, et al. Validity and utility of the DSM-5 severity specifier for binge-eating disorder [published online ahead of print February 28, 2017]. Int J Eat Disord. PubMed doi:10.1002/eat.22696

4. Dakanalis A, Bartoli F, Caslini M, et al. Validity and clinical utility of the DSM-5 severity specifier for bulimia nervosa: results from a multisite sample of patients who received evidence-based treatment [published online ahead of print July 19, 2016]. Eur Arch Psychiatry Clin Neurosci. PubMed doi:10.1007/s00406-016-0712-7

5. Brownley KA, Berkman ND, Peat CM, et al. Binge-eating disorder in adults: a systematic review and meta-analysis. Ann Intern Med. 2016;165(6):409-420. PubMed doi:10.7326/M15-2455

6. Dakanalis A, Carrí  G, Calogero R, et al. Testing the cognitive-behavioural maintenance models across DSM-5 bulimic-type eating disorder diagnostic groups: a multi-centre study. Eur Arch Psychiatry Clin Neurosci. 2015;265(8):663-676. PubMed doi:10.1007/s00406-014-0560-2

7. Wilfley DE, Fitzsimmons-Craft EE, Eichen DM. Binge-eating disorder in adults. Ann Intern Med. 2017;166(3):230-231. PubMed doi:10.7326/L16-0622

8. Masheb RM, Grilo CM. Prognostic significance of two sub-categorization methods for the treatment of binge eating disorder: negative affect and overvaluation predict, but do not moderate, specific outcomes. Behav Res Ther. 2008;46(4):428-437. PubMed doi:10.1016/j.brat.2008.01.004

9. McElroy SL. Pharmacologic treatments for binge-eating disorder. J Clin Psychiatry. 2017;78(suppl 1):14-19. PubMed doi:10.4088/JCP.sh16003su1c.03

10. Regier DA, Kuhl EA, Kupfer DJ. The DSM-5: classification and criteria changes. World Psychiatry. 2013;12(2):92-98. PubMed doi:10.1002/wps.20050

Antonios Dakanalis, MD, PsyD, PhDa,b

Massimo Clerici, MD, PhDa,c

aDepartment of Medicine and Surgery, University of Milano Bicocca, Monza, Italy

bDepartment of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy

cMental Health Department, San Gerardo Monza Health and Social Care Trust, Monza, Italy

Potential conflicts of interest: The authors report no financial or other affiliation relevant to the subject of this letter.

Funding/support: None reported.

Role of the sponsor: None reported.

J Clin Psychiatry 2017;78(7):e841

© Copyright 2017 Physicians Postgraduate Press, Inc.

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