Binge eating disorder (BED) is a research diagnosis in the Diagnostic and Statistical Manual of Mental Disorders
, Fourth Edition
]. BED is defined by recurrent binge eating episodes that occur, in contrast with those in bulimia nervosa, in the absence of inappropriate weight control behaviors (for example, purging). A series of characteristics are associated with binge eating, such as rapid consumption of food, eating until uncomfortably full, and marked distress regarding the behavior. For a BED diagnosis, binge eating episodes must have occurred at least twice weekly over a period of 6 months.
International experts for eating disorders agree that BED is a valid eating disorder diagnosis and should be included in DSM-5 as an official diagnosis [2
]. BED is the most prevalent eating disorder, affecting 2% to 5% of the general population, and both genders appear to be equally affected [3
]. The disorder is associated with substantial medical [4
] and psychological comorbidities [5
]. Furthermore, overweight and obesity are common in patients with BED. Up to 30% of participants in weight loss programs meet criteria for BED [6
], and higher levels of binge eating have been linked to overweight and obesity [7
]. Obese patients with BED display marked eating disorder psychopathology and comorbidity with other psychiatric disorders. Given the associated comorbid somatic and mental sequelae, BED is argued to be a disorder of clinical significance causing huge costs for the medical system [8
According to current meta-analyses and clinical treatment guidelines, cognitive-behavioral therapy (CBT) is regarded as the first-line specialty treatment for BED [9
]. Controlled studies of CBT generally report substantial reductions in binge eating and in most associated problems such as comorbid psychopathology and impaired quality of life [13
Although CBT is the gold standard treatment for BED patients, this intervention is not offered areawide, leading to delayed delivery of adequate treatment. An alternative to classic face-to-face CBT and a potential means by which to disseminate adequate treatment for eating disorders is guided or pure self-help for patients with BED. So far only a few open studies or RCTs have evaluated self-help interventions in BED [7
]. Nearly all of them used book-based self-help with manuals detailing CBT for binge eating, primarily the book Overcoming Binge Eating
]. One study used a CD-ROM-based self-help intervention [18
]. Results of single studies, meta-analyses, and systematic reviews [13
] have shown that guided self-help is superior to waiting list in patients with BED. Patients using self-help modalities did better than controls in reducing days with objective binge eating episodes (OBEs), in reducing hours spent binge eating, and in improving the specific eating disorder psychopathology [15
]. However, the evidence regarding guided self-help is limited to a small number of studies, and further, larger randomized-controlled studies (RCTs) are needed.
Several experts have outlined potential advantages of guided self-help treatments. (1) They allow evidence-based treatments to be offered with minimum delay. (2) They are popular and acceptable to many patients. (3) They can be offered at low cost. (4) They respect patients’ privacy and avoid their embarrassment about needing psychotherapy. (5) They allow patients to work at their own pace, which is particularly important for highly anxious or depressed patients who have difficulty to focus during a session with a therapist. (6) They allow patients to renew or update treatment as often as they wish and at no extra cost. (7) They could be appropriate for less severe conditions in primary care delivered by trained nonspecialists or could be the first step in patients’ search for a more comprehensive treatment.
Only one study directly compared guided self-help with face-to-face psychotherapy [19
]. In this trial, interpersonal psychotherapy (IPT; n
75) and guided self-help based on CBT using a book-based format (n
66) were equally effective, with 4-week abstinence rates from OBEs in more than 60% of the patients that were maintained over a follow-up period of 4 years [25
]. However, IPT was more successful than self-help in retaining patients in the trial. Moderator analyses provided evidence for a specificity of treatment effects; for example, a high baseline binge eating frequency had a negative impact on remission rates in the guided self-help condition, but not in the IPT condition.
Until recently, little has been done on technology-enhanced delivery of CBT-based interventions for BED. In a RCT comparing the efficacy of a 10-week CD-ROM intervention, a group CBT, and a waiting list, there were comparable reductions in days with OBEs in the group CBT and in the CD-ROM condition, with better results in the two active intervention groups compared to the waiting list [18
]. However, the conclusions of this study were limited by a high rate of dropout. At present, there is only one internet-based BED treatment study comparing a guided self-help approach with a waiting list [20
]. Seventy-four women were randomized to either a 6-month online program with a 6-month follow-up or a 6-month waiting list. Guidance consisted of regular e-mail contact with a coach during the whole intervention. The number of OBEs and eating disorder psychopathology significantly improved after the internet self-help treatment intervention. Improvements were maintained at 6-month follow-up. Overall, a transfer of CBT-based self-help techniques to the internet was well-accepted by patients and showed positive results for eating disorder psychopathology. For many participants, it was their first eating disorder treatment. However, internet-based, guided self-help has not yet been directly compared with standard face-to-face CBT.
An additional important question is for whom the face-to-face and self-help modalities of CBT work [10
]. Evidence from the planned treatment trial would allow specifying how to adequately match patients with treatments. A comparison of previous studies did not show any clear difference in moderators for both face-to-face and self-help modalities of CBT. More severe eating disorder psychopathology and general psychopathology inconsistently predicted poor treatment outcome in both modalities [26
]. From a stepped care approach, as advanced by the National Institute for Clinical Excellence guidelines [11
], patients with more severe psychopathology should benefit more from face-to-face CBT, whereas internet-based guided self-help should be sufficient for patients with low psychopathology. Further variables with at least some evidence for predictive effects on treatment outcome are psychiatric comorbidity, self-esteem, quality of life, age at onset of the eating disorder or of overweight, and patient expectation and motivation (for a summary, see [27
The main goal of internet-based guided self-help for overweight and obese patients with binge eating disorder (INTERBED) is to compare the short- and long-term outcomes of two treatments for adult patients with BED: internet-based guided self-help treatment (GSH-I) and CBT in an individual setting. In addition, we will investigate predictors and moderators of treatment outcome. Finally, we will evaluate the cost-effectiveness of both treatments.