What it is, Why you get it, and How you recover from it

What is Binge-Eating Disorder?

Well, for starters, recognition of Binge Eating Disorder as “an actual thing” heralded quite a breakthrough in the politics of obesity. For decades, only Anorexia and Bulimia had held Eating Disorder status. Fatties were just fatties. So for the global Psychology associations to acknowledge that there was something specific and important often underlying obesity was quite ground-breaking.

But not everyone who is overweight or obese has Binge Eating Disorder. Obviously.

Psychologists and Psychiatrists refer to The Diagnostic and Statistical Manual of Mental Disorders (DSM) for diagnostic accuracy.

Here are the scientific criteria that need to be met for a legitimate diagnosis of Binge Eating Disorder:

There are 5 conditions that the patient needs to fulfil, and then there is also a specifier for severity (as per the DSM).

1. Recurrent episodes of binge eating.

An episode of binge eating is characterized by both of the following:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
2. The sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

So, we need to eat a LARGE AMOUNT, in an EPISODE (as opposed to just eating CONSTANTLY, grazing and snacking).  

And we need to feel COMPLETELY OUT OF CONTROL of ourselves, what we are eating, and how much of it.

So a binge is AN EVENT. It’s not a style of eating. It has a beginning, and an end, and is characterised by consuming a large amount of food and feeling completely at the mercy of the compulsion, until it runs its course. Binge-eating episodes are associated with three (or more) of the following:

1. Eating much more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of being embarrassed by how much one is eating
5. Feeling disgusted with oneself, depressed, or very guilty after overeating

So, there are 5 points here, and the patient needs to objectively relate to at least 3 of them. Eating quickly, eating until STUFFED, eating a lot despite not being hungry, eating alone, in shame, and feeling disgusted, depressed and guilty thereafter. Marked distress regarding binge eating is present.

3. Marked Distress Around The Condition.

Isn’t it interesting that it’s only Binge Eating Disorder if the person is incredibly concerned and overwhelmed by it? According to this criteria in the DSM, if there’s not distress, there’s no disorder.

4. Frequency of Binge-Eating Episodes

At least 1 day a week for 3 months (DSM-5 frequency and duration criteria).

So that’s at least weekly for 3 months… At least 12 episodes of binge-eating in a 90-day cycle.

5. The binge eating is not associated with the regular use of inappropriate compensatory behaviour (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

The DSM always include room for ‘differential diagnosis’ (other things it could be…). Any time a binge evokes a way of mitigating the binge, it becomes Bulimia. And if a binge occurs in an Anorexic patient, it obviously is part-and-parcel of that disease.

The DSM classifies BED into mild, moderate, severe and extreme, as follows:

• Mild:1 to 3 episodes per week
• Moderate: 4 to 7 episodes per week
• Severe: 8 to 13 episodes per week
• Extreme:14 or more episodes per week

Causes of Binge-Eating Disorder

So the bad news is that there is no definitive answer to this question.

There is general acceptance, however, that Binge Eating Disorder is likely a perfect storm of a range of biological, psychological and sociological factors.  Individual suffers may have various of these predispositions in various proportions.

Genetics and Heredity

Binge-eating appears to runs in families.

This doesn’t mean anything in and of itself though, as it makes a case both for NATURE (biology/physiology) or NURTURE (parenting style and family culture.

 It is possible that a dopamine sensitivity is passed down a familial bloodline. Dopamine is a neurotransmitter that is released in response to feelings of pleasure. There is growing research to suggest that ‘dopamine hits’ are, in and of themselves, quite addictive, and that some people’s brains actually seek out situations in which dopamine is released. Many compulsive behaviours create piqued pleasure and result in this ‘dopamine hit’. There’s no doubt that a large influx of sugar and fatty carbohydrates can effect a chemical rush of sorts that can pacify a person, much like a narcotic.

But similarly, familial links might also suggest that binge-eating behaviour was modelledby a parent, and therefore ostensiblytaught, making it learnt behaviour.  Many of the patients I have worked with who binge eat describe how their parent (usually the mother) used to do so, and would even intentionally include the child as something of an ‘eating buddy’. 

Brain Chemistry

There is evidence to suggest that regular binge-eating, with its corresponding effects in the body, actually alters brain chemistry and establishes the bingeing as a hard-wired response to whatever triggers are particular to that particular patient. So much like how driving a motorcar becomes automatic, with systems in the brain that know what to do without conscious effort, bingeing becomes a similarly automatic response.

The Unintended Consequence of Infant Food-Love Association

Infants experience physical hunger as pain and overwhelm, and are then pacified by the combination of physical warmth and closeness and food (held to a chest and provided with food). I’ve written elsewhere about how infants thus associate food with love. This sets us up, as an unintended consequence, to seek comfort from food, almost as an instinct, in later years. Why this affects some people more than others may, again, be a mixture of genetics and environment. 

Psychological Trauma and Somatisation

Most people who self-mutilate (cut themselves) describe the relief of releasing intense emotional pain and overwhelm through a physical means. They say how hurting their bodies somehow ‘gives voice and release’ to their psychic pain. There are, of course, corresponding self-loathing and punitive elements. And a very compulsive edge. Such people seem to have created neurologies that seek this kind of pain, again almost as an addict may seek a narcotic.

Binge-eating can be structurally similar. Excessive and fast consumption of a great deal of food may serve the psychoanalytic function of making physical that which is actually psychological. The physical weight of the food is viewed to have a “squashing” function, pushing down and masking overwhelming negative feeling. 

Many people who binge-eat have a history of trauma that they didn’t and don’t have coping mechanisms as navigation tools.

And for some, bingeing has become so regular that the underlying or triggering emotions are not experienced at all.

Sociological Realities Around Ideal Bodies

This has probably been over-documented, and thus almost emptied of its poignance, but it is a given that we are raised in a world where slimness is idealised, and any minor aberration from this is vilified and even bullied. Parents are often as conscious as peers of their child’s body size, and consciously and unconsciously express their sentiment towards this. This isn’t necessarily malicious; it can be genuine loving fear and concern for a child’s health and social wellbeing in the context of a cruel and cold society. My 6-year old asks me regularly if she’s fat, if she’ll get fat, and how she can prevent becoming fat. In this regard, I must have failed her somewhere along the line. I obviously, with the benefit of hindsight, conscientised her to fatness before she needed to be aware, through my own struggle with weight, eating and then bariatric surgery.

As an aside, for interested parents, a contemporary view is that we should try not to speak of this things to children at all… We should refer to health and wellness… To food as sustenance, rather than “legal” and “illegal”, and we should attempt to promote comfort around ALL food, rather than value judgements that lead a person to conclude that “when I’m GOOD, I eat spinach”, and “when I’m bad, I eat chocolate”. The SPLIT is more destructive than any other approach to food and eating.

That split is evident in the thought process of most people who battle eating issues. Dieting today vs. not-dieting tomorrow, on-the-wagon vs. off-the-wagon, diet food vs. nice food, etc. There is no doubt that a diet mentality creates a sense of deprivation. Deprivation makes one feel hard-done-by, and enough of that would usually cause a recoil into excess.

These are just some of the factors that have been suggested as causative of Binge Eating Disorder. Nothing is definitive, and, in my experience, it’s usually an accumulation of many of these, and even other factors specific to the individual.

Treatment for Binge-Eating Disorder

Academia and the medical fraternity are divided on how best to tackle Binge Eating Disorder, given that it represents a physical disease and a disordered psychology. Obesity specialists argue for weight-reduction strategies initially, arguing that the weight is the most dangerous element, and also that weight loss would scaffold improved self-esteem and better biochemistry anyway. Psychiatric professionals often maintain that any weight-reduction intervention would be thwarted if the eating disorder isn’t treated.

There is no doubt that moderate to severe Binge Eating Disorder would require a multidisciplinary treatment team, and therapy should be viewed as medium-to-long term.

Bariatric surgery is the best option we have for substantial weight loss, but it doesn’t alleviate psychological suffering. Most bariatric patients experience a dramatic reduction in hunger, and a somewhat short-lived inability to eat excessively. This creates a window of opportunity in which both physiology and psychology can be addressed concurrently. If a patient undergoes bariatric surgery and embraces psychological treatment in tandem, the possibility for long-term success is harnessed. 

But bariatric surgery is only PART of a recovery journey. If undertaken as a standalone, the patient is in danger of relapsing badly, and experiencing regain relatedly soon after their surgery. However, if the emotional and mental experience of binge-eating are dealt with before and immediately after bariatric surgery, it is likely that the two prongs together would result in dramatic and lasting success.

A treatment regime for bariatric binge-eaters should include:

• Regular appointments with a suitably-experienced dieticianor nutritionist. A binge can be triggered by hunger, low blood sugar or blood sugar spikes. For this reason, a healthy and nutritious eating plan that focuses on satiety and stable blood sugar would be a great help. 
• Psychotherapy would be invaluable for support throughout the process. It would ideally also address underlying traumas, confusions and overwhelm. The addiction model argues that when we remove our substance of choice, all the pain that we’ve been medicating with that substance might come to the fore. This pain should be held and contained by a skilful therapist, who can, through content and process, offer new ways of being in the world, for the person learning how not to use food to cope.
• Programs that teach appropriate tools, skills and strategiesto integrate into daily experience, as alternatives to binge-eating. Psychotherapy is often less well positioned to offer this than something more formal and didactic. Therapy is more about a safe space for the patient to debrief in. A skills-based program is useful in a different way to therapy, in that it imparts practical and actionable interventions that the eating disordered person should learn to apply.  

My 8-week BARIATRIC MIND MASTERSonline program is exactly that… Steeped heavily in the principles of Dialectical Behaviour Therapy, Bariatric Mind Masters offers psychologically sound teaching to binge eaters, offering robust tools and strategies for dealing  with the urge to eat excessively. Bariatric Mind Masters uses mindfulness and self-awareness to enhance emotion regulation. It teaches participants to ‘catch’ their feelings and manage them, before they become a binge. It includes modules on compulsive overeating, emotion regulation, head hunger, heart hunger and mindful eating.

It is dangerous, in my view, for binge-eating bariatric patients to ‘free-wheel’, just with their surgery and a bit of anecdotal, social-media acquired rhetoric on head hunger, “fat brain” (I loathe that term and concept) and fundamentalist, overly strict and rigid judgey diet practices.

Support groups like Overeaters Anonymous can also be a invaluable.

• Some form of Physical Therapy–whether personal training, biokinetics etc. Less for the purpose of weight loss than endorphin creation. We know, as psychologists, that 20 minutes of low-grade cardiovascular activity releases sufficient feel-good hormone to be therapeutically significant. 
• Psychiatry– there are certain psychiatric medications available that specifically target and reduce compulsive behaviours, and these can be useful in the treatment of Binge Eating Disorder. Moreover, we know that suffers of BED often have other emotional concerns. If someone’s mood is generally unstable, they may benefit from a mood stabiliser, as this might decrease their emotional vulnerability to binge eating. Anxious and depressed people might also binge less if their anxiety and depression is well managed.