In two hours or less, do you eat an amount of food that is significantly larger than most people would consume in the same time and under similar circumstances? Do you eat until uncomfortably full, and more rapidly than most people would, at least once a week, for a minimum of three months? Do you feel disgusted, depressed, or guilty once you stop?
If you answered yes to any of the above, you fit the criteria for a mental illness being proposed for official inclusion in the next edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-V.
Sharon Kirkey of Canwest News Servies writes that binge eating disorder (BED), a condition that has lingered in the appendix of the DSM since the last edition was published nearly 20 years ago, would be formally promoted to the main manual under proposed revisions for the next edition of DSM.
Doctors and support groups who work with people with eating disorders say it would legitimize what they see every day – an increase in people, notably women over 40 and, increasingly, men, who have lost control over their eating.
But critics are questioning the urgency of making binge eating a distinct, free-standing diagnosis alongside bulimia and anorexia nervosa. They wonder how reliably doctors who are not experts in eating disorders can distinguish between someone who binges for psychiatric reasons and someone who merely overeats. Skeptics worry that, with the nation in the grips of an “epidemic” of obesity, thousands of people struggling with weight issues could suddenly be tagged “disordered” and potentially treated with Prozac-like antidepressants and other drugs. Some legal experts in the U.S. are warning that, if an overweight person is fired from a job they could claim they were fired for having a mental illness: BED.
“Why should people eating too much be considered pathological?” says Stuart Kirk, professor of social welfare at the School of Public Affairs at the University of California, Los Angeles, and co-author of Making Us Crazy; DSM: The Psychiatric Bible and the Creation of Mental Disorders.
“They’re saying, ‘We’re arbitrarily going to put the marker here: If you do it this much, and you feel this bad, and you do it for two weeks or three months . . .’ They’ve already made the assumption that wherever they draw that line, that that’s going to be considered the brain disease,” Kirk says. “That will expand the market for drug companies.”
Dr. Valerie Taylor agrees that there is a risk of over-diagnosing binge eating. “But it’s not a new diagnosis. It’s been out there for a while, and everybody with obesity hasn’t been diagnosed with binge eating disorder,” says Taylor, mental health lead for the Canadian Obesity Network and assistant professor in psychiatry and behavioural neurosciences at McMaster University in Hamilton.
“So if it moves from the provisional category to one that’s actually accepted, it’s not going to suddenly tweak people to think, ‘Oh, if you’re obese, you have binge eating disorder.” Taylor says binge eating disorder is a true clinical entity, and that it’s not simply eating too much at Thanksgiving. Rather, the binges occur weekly for at least three months, and people “simply can’t stop. They really feel there is something else driving their eating.”
“And if you talk to somebody who has weight difficulties but who doesn’t have binge eating disorder, if you ask them some of the questions required to make the diagnosis – do you really feel like this is beyond your control? Do you really feel angry, upset, distressed afterwards? – they can’t relate to that. That’s not them.”
Obesity isn’t synonymous with binge eating disorder, she says, nor is binge eating disorder synonymous with obesity.
Legitimizing the illness, she says, will help make it easier to get funding for research and treatment.
Cognitive therapy and other interventions can help people normalize their eating, she says, “so that you never get to the point where you’re starving.”
For Robin Moore, the binge rituals would begin mid-afternoon and continue until late in the night. The 45-year-old Toronto woman has struggled with her weight since she was 10. She used food not just to deal with emotional pain, but with any emotion, good or bad. When she gave up smoking in her 20s, she gained more than 100 pounds in three years.
“I was just binging constantly. I would eat enormous amounts of food.” She would eat normally when she was around other people. But when she was alone in her apartment, all bets were off. “There was no hitting the pause button.”
Her weight has ranged from 153 to 303 pounds. “The agony of being an overweight or obese female in this society is even more damaging, and the self-shame – it was just horrendous.”
She is now in recovery after years of help that started in 1998 at Sheena’s Place, a Toronto support centre for people with eating disorders.
“Until I dealt with what was going on in my mind I was not going to be able to step into recovery.” Now a certified life coach, she works with people struggling with BED and weight issues.
Anne Elliott, program director at Sheena’s Place, says some people restrict their food intake so much during the day that, by the time they start eating, they’re starving and they can’t stop. Others don’t restrict during the day, but then eat everything in sight at midnight, she says.
Adding binge eating to the manual of mental illness would validate “that this is real, it’s not a figment of people’s imagination, it’s not a ‘discipline’ problem – ‘just stop eating and get on another diet,'” adds Julie Notto, program coordinator.
“We glamorize thinness in our culture, that’s what we value. No one wants to talk about the fact that, at midnight, they’re so overwhelmed that they eat everything in their fridge. No one wants to talk about that.”
But Dr. Allen Frances says that a “fair proportion of the population” cycles between restricting and binging.
“But that something happens in life does not make it a mental disorder,” says the former chairman of the department of psychiatry at Duke University in Durham, N.C.
A nationwide U.S. survey by Harvard-affiliated McLean Hospital published in 2007 found binge eating disorder afflicts 3.5 per cent of women and two per cent of men at some point in their lives, making it more common than bulimia or anorexia. But Frances predicts the diagnosis will spread rapidly once it graduates to the main text of the DSM.
Dr. Timothy Walsh, chairman of the work group for eating disorders for DSM-5 and professor of psychiatry at New York State Psychiatric Institute, Columbia University Medical Centre, says that almost 1,000 papers have been published on binge eating disorder since the last edition of the psychiatric manual was published in 1994.
“One of the things we know, with a high degree of confidence, is that people with binge eating disorder, compared to other similar folk of similar weight, and many of these people are obese, have a substantially higher frequency of mood and anxiety problems,” Walsh says. “They are more unhappy than their peers. That’s the real bottom line.”
There’s also emerging evidence, he says, that people with binge eating disorder respond to forms of treatment they might not get “if they just went to a doctor for a weight problem.” Those treatments include psychotherapy and a “range of medications” that help with mood disturbances and out of control eating behaviors.
The diagnosis should be made by a trained mental health professional, says Walsh, and not just casually handed out like business cards.
“These are sensitive criteria, and they require some more thorough assessment of a person’s difficulties than a simple, ‘Do you overeat now and again?'”