Here's a question I ask all of my new patients: "Are you a binge eater?"
About 80% of the men and women I see have to stop and think, yet they do not have anything resembling binge eating disorder. Many of those who eat the SAD (Standard American Diet) feel that they are under the control of food. Despite their best efforts, they may find themselves at the other end of an entire bag of Fritos or a full pint of ice cream. They "wake up", trance-like, with a spoon in one hand and a dazed expression, like an alcoholic after a lost weekend. Yet this is not binge eating disorder as experts would describe it. The Fritos gorge is more of a normal variant of eating behavior in America.
The definition of a binger look like this (Wikipedia):
▪ Periodically does not exercise control over consumption of food.
▪ Eats an unusually large amount of food at one time, far more than an average person would eat.
▪ Eats much more quickly during binge episodes than during normal eating episodes.
▪ Eats until physically uncomfortable and nauseated due to the amount of food consumed.
▪ Eats when depressed or bored.
▪ Eats large amounts of food even when not really hungry.
▪ Usually eats alone during binge eating episodes in order to avoid discovery of the disorder.
▪ Often eats alone during periods of normal eating, owing to feelings of embarrassment about food.
The difference between a normal, out-of-control American eater and a true binger is one of degree, compulsion and emotional tone. Bingers describe feeling completely out of whack when binging. They also often feel that they have an “on” and “off” switch. When they are restricting food by dieting, they can be very, very good at it. One bite of the wrong food, however, or one day of unbalanced emotion can throw everything off the rails.
I specialize in treating obesity and not in the management of eating disorders, but inevitably…because of their weight… bingers make their way into my practice. When I am successful at identifying them, I always recommend that they get counseling from an eating disorders program or specialist concurrent with our treatment.
Herein lies the rub.
Most eating disorder therapists employ a form of dialectical behavior therapy. This is a treatment based on helping patients to identify stressors and maladaptive behaviors and finding healthy alternatives. At the same time, therapists usually advise patients that they must stop restricting food. Learning to control intake naturally and accept the fact that they may never be as thin as they might like is seen as an important pillar of recovery.
But I have a question about this, and I ask for help from readers in sorting it out:
The on/off nature of binging makes me suspicious that there might be a physiological trigger. Many bingers have described to me their intense compulsions to eat certain foods and the feeling of being utterly out of control after consumption. While it’s certainly possible to see the compulsion to binge as a psychological problem, it’s not the only---or even the most logical---explanation.
When I was in my twenties and thirties, I routinely ate huge meals and consumed whole cheesecakes and loaves of bread in one sitting. I ate whenever and whatever I wanted, in enormous amounts. Yet no one suggested that I had an eating disorder. Why not? Because I didn’t get heavy. If I had been obese as a result of my eating, I would no doubt have developed shame, depression and an entire approach and avoidance cycle around eating. I would likely have ended up in the office of an eating specialist.
Recently, one of my patients who has BED was advised to entirely stop restricting food intake. She gained an unacceptable amount of weight rather quickly. In discussing it with her, I shared my discomfort with the direction to eat without restriction. Because of our SAD food culture, we are surrounded by dangerous food substances, some of which appear to be particularly toxic and addictive to certain people. It seemed to me that telling such a person to eat whatever he wanted was tantamount to suggesting that he drive a car without regard to the consequences. Go ahead: Hit someone. Crash into a store. Run a red light if you feel like it.
I have always had a problem with critics of diet (the “diet is a four letter word” folks) because I think they base their objections on a misinterpretation of the idea of restriction. Restriction has a pejorative feel. It’s a tough word that doesn’t feel good to us. But suppose we substitute the words “eat with intelligence”. To eat with intelligence, one would need to know the foods that react well with ones body and those that are dangerous and destructive. It would only make sense to avoid the latter at all costs. Some would call that restriction, but I would call it EWI.
Bingers, like all humans, undoubtedly come in many permutations. For those whose binging is primarily emotional, based on previous trauma or an offshoot of significant psychological issues, an approach that asks the patient to learn dietary modulation without restriction may be appropriate. However, I suspect that for many people binging may occur in those who are highly sensitive to the chemical reactions of certain modern foods in their brains. For these people, learning to EWI rather than eat unrestrictedly would seem to be a much better treatment.
I am very interested in the experience of bingers and eating disorder specialists who may read this blog. Has DBT worked for you? Have you learned to eat “unrestrictedly” while controlling your desire to binge? I am completely open to having my theory taken down. Let me know if I’m wrong or if your experience suggests I might be onto something. Please write to me here or on Facebook at Refuse to Regain: Barbara’s World, or on Twitter at BBerkeleyMD.