In Part I of this series I laid out an unfortunate confluence of circumstances that make the inclusion of binge eating disorder (BED) as a standalone eating disorder in the DSM-5 questionable given the lack of strong clinical data to support its inclusion alongside the co-occurring efforts of several pharmaceutical companies to extend drug patents by having approval of their use for BED.
Now we’ll review what the science actually does tell us about binge eating. I had thought I might need three parts to this series, but it flows better with just two.
There is only one kind of truly medically unambiguous form of binge eating and that would be what is seen in patients with rare congenital conditions, such as Prader-Willi Syndrome. These individuals experience no sense of satiation (being full). i Of course, this kind of binge eating is merely one symptom in a host of congenital anomalies generating numerous developmental and medical complications.
But as a psychiatric disorder BED, and to a certain extent night eating syndrome (NES) as well, were primarily conjured into being because there is a cultural bias that individuals cannot have a restrictive eating disorder if they are not underweight, or at the very least average weight. And I will now go on in the rest of this post to prove that point.
BED was introduced into the DSM-IV as a psychiatric disorder needing further study. So between 1994 and 2013, when a patient presented with the symptoms of BED, they were actually diagnosed with eating disorder not otherwise specified (EDNOS).
Dr. Albert Stunkard was the pioneering researcher who, in 1959, identified night eating syndrome (NES) as well as BED. ii NES is not an eating disorder as much as it is a circadian rhythm disorder and it is responsive to full-spectrum light treatment. iii
Many with restrictive eating disorders are sure that they have NES because they “binge” in the evening. However, the daytime anorexia is driven by the underlying drive to avoid food that marks the presence of a restrictive eating disorder. Those with NES experience daytime anorexia not because they are trying to compensate for the previous night’s intake of food and their consumption of food is average in proportion— just shifted in time frame when compared to healthy controls. It takes a skilled therapist or physician to be able to differentiate between a patient’s anxiety about their propensity to binge and what the actual biological mechanisms underlying it might be.
Right from the outset, the inclusion of BED in the 1990s under the EDNOS category was about differentiating bulimia (BN) from this new classification. The differentiation depended almost entirely on the patient’s size. And that was based entirely on the unscientific premise that no one who is an above-average weight could be under eating relative to energy requirements. [see Gaining Weight Despite Calorie Restriction for details on that fallacy].
“In 1991 Spitzer et al. suggested that BED should be included in the DSM-IV. Their rationale for this proposal was that many individuals with marked distress about binge eating could not be diagnosed with bulimia nervosa (BN). People with the BED syndrome have episodes of binge eating as do patients with BN but unlike the latter they do not engage in compensatory behaviors such as self-induced vomiting, the misuse of laxatives, diuretics or diet pills, fasting and excessive exercise. They indicated that such patients are common among the obese in weight control programs.” iv (emphasis mine).
By definition, any individual (no matter her size) in a weight control program is constantly compensating for binges because she is returning to a reduced intake of food relative to her actual energy requirements. And therefore, by definition, it is as much of a compensatory behavior as fasting, vomiting or abusing laxatives. And that means that the distinction between BN and BED rests entirely on the degree and type of compensation applied. The creation of BED occurred to classify the many people distressed with their predilection to binge who could not receive a diagnosis of BN purely because the type of compensation had been narrowly defined as part of the diagnostic criteria.
“The relationship of the BN-NP [DSM-IV subcategory of BN non-purging] group to BED seems rather problematic. In the present study the differences between BED and BN-NP seem to be more of degree than of type, with patients showing similar profiles as regards the specific psychopathology of eating disorders measured with the EDI and BUT and comparable levels of social and occupational maladjustment secondary to the eating behavior.” v
To put it all in perspective, this process of codifying psychiatric illness would be somewhat akin to having originally defined asthma as coughing, wheezing, shortness of breath and fair skin. Then, when darker-skinned individuals show up in doctor’s offices with wheezing, coughing and shortness of breath, they are unable to be diagnosed with asthma and therefore cannot be treated for the condition. So a separate diagnosis is created called azeina (azein is the Greek word origin for asthma actually) for those with darker-skin presenting with coughing, wheezing and shortness of breath.
It certainly goes a long way towards explaining why the DSM has increased in size with each iteration, even as they remove conditions like asthma and homosexuality from the roster of mental disorders.
There are no systematic reviews available on the strength of the diagnostic criteria of BED when compared to BN. In fact, most scientific studies tend to combine patients with BN and BED for assessment and treatment. A perfect example of this melding of presumably distinct diagnoses is a study entitled: A Comparison of Black and White Women With Binge Eating Disorder. vi
In the study, 150 women had a primary diagnosis of BED (98 white and 52 black women). They were identified as having BED by matching the following criteria:
- minimum average frequency of binge eating episodes of twice a week for 6 consecutive months,
- distress over binge eating, presence of three behavioral indicators of loss of control over binge eating,
- and absence of regular extreme compensatory behaviors (emphasis mine).
Extreme compensatory behaviors included vomiting; use of laxatives, diuretics, or other drugs for weight control; fasting (eating nothing for 24 hours or more); and excessive exercise (exercising despite pain, against a physician’s advice, or so much that it interferes with responsibilities).
There were 67 cases with BN and 70 cases of EDNOS, of which 53 were sub-threshold BED and 10 sub-threshold BN. That would mean that 91% of the individuals in either the control group or the experimental group (the authors are not clear in their results) had diagnosable eating disorder symptoms distinct from the inclusion criteria, and that would make the data amassed in the study absolutely meaningless. You cannot compare white and black women with BED when 91% have related but supposedly distinct psychiatric conditions.
Despite the clear evidence that BED is utterly interchangeable with BN, I am still of the opinion, having revisited all the literature that predates the inclusion of BED in the DSM-5, Albert Stunkard and his colleagues’ observations still stand. In fact, Dr. Stephen Wonderlich had this to say on the topic of Stunkard’s assessment in the reference section of his book Eating Disorders Review, Part 1:
“Stunkard A and Allison KC (2003) Binge-eating disorder: disorder or marker? Int J Eat Disord. 34: S107-16.
This provocative and important paper from the investigator who originally described binge eating contends that the latter is best viewed as a marker of psychopathology among the obese rather than as a disorder in its own right. The authors present convincing evidence that the presence or absence of BED is not a useful distinction in selecting treatment for obese patients.” vii
Basically, there are rare individuals out there for whom binges without truly any form of compensatory behavior (extreme or subtle) will reflect one of many symptoms they experience associated with a distinct psychiatric condition unrelated to eating disorders. These people deal with personality disorders that may involve more serious breaks with consensus-based reality; significant reduction in quality of life and ability to live independently; and likely periodic hospitalizations during crises.
Most of you know, because I have mentioned it in previous blog posts, that at the UCSD EDC2014 conference there was a panel discussion held with Drs. Stephen Wonderlich and Carol Peterson. Their presentation had covered integrative-cognitive affective therapy (ICAT) and its evidence for use in treating BN [Part VII-A UCSD EDC2014 Review and Part VII-B UCSD EDC2014 Review]. Dr. Wonderlich had mentioned at the end of his portion of the presentation that they were now investigating ICAT’s usefulness for treating BED.
So, not surprisingly, I asked about the inclusion of BED as a standalone eating disorder within the DSM-5 and had a brief post-panel discussion with the two researcher/clinicians on the topic as well. I referenced Albert Stunkard’s material that Wonderlich himself had referenced as per the above quote. As a reminder, Wonderlich was a member of the eating disorder work group for the development of the DSM-5.
To paraphrase Dr. Peterson’s comment to me, she confirmed that these patients diagnosed with BED do usually turn out to be under eating relative to their energy requirements— compensating for ongoing binges that are in fact just a biological drive to rectify those energy deficits. She stated that these patients would not self-identify as having a problem with restricting food intake and that they would certainly not seek treatment for it.
The point is that in a society steeped in fattism, the distress these individuals face is that they are not at a socially acceptable level of thinness and they are forever trying to lose weight through habitual under eating. The binges merely reflect the body’s effort to rectify the progressive energy deficit. And as Dr. Peterson clarified for me, these people seek help to stop the binges and once they are in professional care they can at least be encouraged to stop under eating relative to their energy needs.
That would mean that the primary reason for BED’s inclusion as a standalone eating disorder in the DSM-5 is that the ends justify the means. Overlooking the iffy ethics, the problem with that motivation to help is that everything depends upon all psychiatrists being made fully aware that the binges are superfluous to the issue of restriction, and that treatment for these individuals is the same as for all other facets of a restrictive eating disorder: approach and eat the food.
Drs. Peterson and Wonderlich are steeped in expertise on the topic of treating BED, so I have no doubt that if you are lucky enough to walk into their offices because you want to stop uncontrollable binges, they will apply dutiful differential diagnostic criteria to rule out the possibility that you are dealing with a serious personality disorder, and then effectively treat your restrictive behaviors.
But in a society wallowing in the presumed immorality of fatness, there is a much greater chance of walking into a psychiatrist’s office to be prescribed amphetamines to help you be more successful in applying your restrictive behaviors. Two great articles on the approval of amphetamines for BED treatment if you are interested: Promoting Amphetamines for Over Eating and Did the FDA Forget About America’s First Amphetamine Epidemic?
If you have binge eating behaviors as a symptom of a personality disorder, then this blog post will not distress you in the slightest. You have known for years that your underlying condition is where your focus for treatment lies and BED in the DSM-5 has no bearing on your treatment plan. In fact, you might find it irritating that all these individuals with restrictive eating disorders now think they have a problem with binge eating behaviors, when they have absolutely no idea what your experience with true binge eating is like in the slightest.
So what does BED really look like? Well, azeina is still asthma and binge eating disorder is still bulimia nervosa.
Or, to be more neurobiologically accurate: BED is a subcategory of BN; which is, in turn, a subcategory of a restrictive eating disorder; which is, in turn, a subcategory of an anxiety disorder; which is, in turn, a biological propensity for a hyperactive threat identification system in the brain. And the activation of that propensity rests with innumerable environmental inputs and experiences unique to each individual.
i Cassidy, S. B., & Driscoll, D. J. (2009). Prader–Willi syndrome. European Journal of Human Genetics, 17(1), 3-13.
ii Stunkard, A. J. (1959). Eating patterns and obesity. Psychiatric Quarterly, 33(2), 284-295.
iii Goel, N., Stunkard, A. J., Rogers, N. L., Van Dongen, H. P., Allison, K. C., O'Reardon, J. P., ... & Dinges, D. F. (2009). Circadian rhythm profiles in women with night eating syndrome. Journal of Biological Rhythms, 24(1), 85-94.
iv Dingemans, A. E., Bruna, M. J., & Van Furth, E. F. (2002). Binge eating disorder: a review. International Journal of Obesity, 26(3), 299-307.
v Ramacciotti, C. E., Coli, E., Paoli, R., Gabriellini, G., Schulte, F., Castrogiovanni, S., ... & Garfinkel, P. E. (2005). The relationship between binge eating disorder and non-purging bulimia nervosa. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 10(1), 8-12.
vi Pike, K. M., Dohm, F. A., Striegel-Moore, R. H., Wilfley, D. E., & Fairburn, C. G. (2014). A comparison of black and white women with binge eating disorder. American Journal of Psychiatry.
vii Wonderlich, S., (2005). Eating Disorders Review, Part I, Radcliffe Publishing, UK, p.40.