The dividing line between what represents normal variation in behavior and an actual behavioral disorder can often be very hard to ascertain.
In no particular instance is this more relevant than when discussing eating disorders. The dividing lines between simple overeating, under eating, dieting, and disordered behaviors regarding eating are admittedly somewhat fuzzy, and the difference between a diagnosis of an eating disorder and normal variation in eating patterns is based on both quantitative and qualitative criteria. A large number of individuals in industrialized countries habitually overeat and are obviously prone to binge eating episodes on occasion, but the majority these individuals most likely do not meet the criteria for a binge eating disorder. A useful comparison is the notion of telling the truth. Most of the readers of this article can relate to the fact that they do not always tell the truth and may often exaggerate or underreport issues; however, they would not formally qualify for the label of being a compulsive liar.
The characterization of what constitutes a behavioral disorder and how behavioral disorders present differently from normal variations in behavior is based on several different dimensions that include the notions of:
- Consistency: The behavior displayed by a person with a behavioral disorder will occur across many different situations and different contexts.
- Being extreme: The behavior of a behavioral disorder that occurs across many different contexts is considered to be extreme in the overwhelming majority of these contexts.
- Rigidness: The behavior maintains its extreme presentation and consistency across different contexts, indicating that it is very difficult to adjust or change.
- Being dysfunctional: The behavior in a behavioral disorder will always result in some type of dysfunctional or negative consequences for the person. These dysfunctions or negative consequences can involve a number of different aspects of the individual’s life, including their relationships, health, emotional and psychological wellbeing, occupation, school, etc.
- Demonstrating a loss of control: Despite the negative consequences from the person’s behavior, they continue to engage in it. Moreover, many individuals with behavioral disorders have often made numerous attempts to stop or cut down on these behaviors, but are unable to do so.
One criticism of the notions of behavioral disorders and psychiatric/psychological disorders is that they tend to pathologize normal behaviors; however, when these above notions of the separation between the normalcy and disordered behavior are considered, it becomes clearer that there is a quantitative and qualitative difference between the two.
Behavior that is considered to fall within normal variation is characterized by significant variability, the ability of the individual to adjust the behavior to the situation, the behavior not being considered extreme in its presentation in all instances, and the behavior not being consistently repeated when it results in dysfunctional consequences for the person. Normal variation in behavior results in the behavior being controlled by the individual to account for the situation or its consequences, whereas individuals with behavioral disorders appear to either lack the ability to control or adjust their actions or to intentionally not engage in controlling their behavior over multiple contexts despite repeated negative consequences for the behavior.
Binge Eating Disorder
A binge eating disorder (often abbreviated as BED) is a disorder that is diagnosed when an individual repeatedly consumes a larger amount of food over a particular period of time that is obviously larger than the majority of people would eat under similar circumstances and over a similar time period. The context of the situation obviously plays an important role in determining whether the person is expressing a disorder or not. The notions of “significantly larger amounts of food” and “timespan” or “time period” with respect to the particular episodes of binge eating require a clinical judgment in the diagnosis. However, the binge eating episodes must occur on average of one time per week over a minimal three-month period before the disorder can be diagnosed.
The American Psychiatric Association (APA) uses a formalized set of diagnostic criteria to help clinicians designate BED:
- The person eats at a more rapid pace than would be considered normal.
- The person continues eating until they are uncomfortably or overly sated.
- The individual continues to eat large amounts of food even if they are not physically hungry.
- The person often eats alone because they may be embarrassed by the amount of food they eat during these episodes.
- The person often experiences disgust, guilt, or even depression following their binge eating episode.
The person must satisfy three of the above five criteria for BED to be considered. In addition, qualifiers for binge eating episodes offered by APA include:
- The person must eat in the above matter on an average of once a week for a period of at least three months.
- The person has the experience of a lack of control during these eating episodes.
- During these eating episodes, they consume significantly more food than the majority of people would eat under similar circumstances and in a similar time period.
BED is a disorder that presents at different extremes. APA also allows for these extremes to be recognized such that:
- Mild BED: This is diagnosed when there are 1-3 binges per week.
- Moderate BED: This is diagnosed when there are 4-7 binges per week.
- Severe BED: This is consistent with 8-13 binges per week.
- Extreme BED: This involves more than 13 binges per week.
The designation of BED into levels of severity helps a clinician to develop a more effective treatment approach tailored to the level of severity of the disorder.
It is important to understand that binge eating behavior is common in other disorders, including eating disorders like bulimia nervosa. An individual would not be diagnosed with bulimia and a binge eating disorder together because in the majority of cases, the binge eating behavior is better explained by the bulimia (the notion that a binge eating disorder cannot be diagnosed if the behavior is better explained by another psychological disorder). In addition, BED is not diagnosed when the behavior can be better explained by an individual’s use of drugs or by some other medical condition such as a brain injury.
A number of clinical sources indicate that BED is diagnosed at a rate of 2:1 for females to males and is significantly more often diagnosed in individuals under the age of 30 than in people over 30 years old. It appears that relatively equal distributions of BED diagnoses occur across different ethnic groups.
BED is diagnosed significantly more often in individuals who are considered to be obese or overweight and who are seeking professional treatment to control their weight; however, it can also be diagnosed in individuals who are not considered to be overweight. The majority of individuals who would be considered to be obese are not diagnosed with BED and do not meet the formal criteria for binge eating. The prevalence of BED appears to be 2:100 individuals in the overall population, but the prevalence of BED in obese individuals appears to be around 8:100.
BED is also associated with a number of a negative consequences, including:
- Physical issues: These include higher mortality rates, cardiovascular disorders, weight gain, and an increase in the use of medical services.
- Less satisfaction: Individuals who are diagnosed with BED consistently report being significantly less satisfied with their lives on formal measures than individuals without psychological disorders.
- Psychological issues: Higher rates of adjustment disorders, major depressive disorder, bipolar disorder, anxiety disorders, and substance use disorders are associated with BED; however, the rates of these issues in individuals diagnosed with BED remain lower than the rates of these issues diagnosed in individuals with other eating disorders, such as bulimia nervosa and anorexia nervosa.
The most common types of substance use disorders that occur in individuals with BED are stimulant use disorders as a result of individuals taking stimulants, diet aids, and even amphetamines to lose weight. Individuals with BED are also diagnosed with co-occurring alcohol use disorders more frequently than individuals are diagnosed with alcohol use disorders in the general population. Of course, the increased susceptibility to the development of a substance use disorder as a result of being diagnosed with BED is not restricted to these substances alone, and individuals with this disorder can have co-occurring disorders that include any type of substance of abuse.
BED is an eating disorder, and as mentioned above, all eating disorders are often associated with a higher risk to develop substance use disorders. Eating disorders at one time were considered to be disorders that resulted from issues with impulse control in these individuals. The connection between this lack of impulse control and eating, substance abuse, and other behaviors was considered to be in an important link in the explanation as to how eating disorders develop.
In addition, many individuals with moderate to severe substance use disorders also display issues with impulse control on formal measures. The research does strongly suggest that being diagnosed with an eating disorder, including BED, is strongly associated with having issues with controlling and monitoring one’s intake of food or even substances like alcohol, but at the same time, not having these issues with control regarding other aspects of behavior. The current conceptualization of these disorders is that they are the result of genetic factors and the interaction of life experiences. Despite all of this research, there is no formal identified cause for the development of any eating disorder.
There is a body of research that suggests that BED should be divided into two subtypes, such that one subtype includes individuals who primarily just engage in binge eating and another subtype that includes individuals who engage in binge eating but also have other comorbid (co-occurring) psychiatric/psychological disorders, including substance use disorders. This designation, along with the above designation regarding the severity of BED, can provide useful information to the clinician who is attempting to treat the individual. Individuals with more complicated presentations, such as comorbidities and/or more severe presentations, are obviously going to require more focused and intensive treatment interventions.
Treatment for BED may include antidepressant medications (particularly selective serotonin reuptake inhibitors) or other medications to reduce an individual’s appetite and assist with weight loss. Individuals with BED and a comorbid psychological/psychiatric condition require more extensive medical management that addresses all their issues. With respect to medical management of BED, it should be noted that just prescribing individual medications does not address many of the long-term behavioral issues associated with this disorder. These individuals require therapy to assist them to develop more functional approaches to eating, provide them with mechanisms to monitor their food intake, and provide them with other important tools, such as stress management tools, to assist in their full recovery.
Typically, individuals diagnosed with BED respond readily to Cognitive Behavioral Therapy (CBT) that directly addresses all these issues and can help the individual develop a more functional approach to eating and other lifestyle issues. CBT can be used in conjunction with medications, other weight loss programs, and other types of supports to assist these individuals and can be administered in an individual or group format.
Treating an individual with a co-occurring substance use disorder and BED would require the individual to receive treatment for both conditions at the same time. Because these individuals will often abuse stimulant drugs, including very strong drugs such as cocaine and methamphetamine or alcohol, individuals should be fully assessed and initially placed in withdrawal management programs. Treatment for the eating disorder can occur at the same time as the withdrawal management program.
Integrated treatment for both disorders should continue once the withdrawal management portion of the recovery program is completed. Integrated treatment is performed using a multidisciplinary team that includes counselors and psychologists, physicians, other treatment specialists, social support groups, peer support, and other supports as needed in the individual’s case. Integrated treatment approaches are long-term approaches that continue to follow the individual as they adjust and move forward in life. Attempting to simply treat BED when an individual also has a co-occurring substance use disorder or just treating the substance abuse and ignoring the BED will result in failure.