Wednesday, July 26, 2006

What Constitutes a Binge. . . Disorder? (Part II)

In its proposed criteria set for Binge Eating Disorder (i.e., the disorder, not just the binge), the APA's Diagnostic and Statistical Manual (IV-TR), includes, in addition to the features of a binge (described earlier), the following points:

A. The 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

B. Marked distress regarding binge eating is present.

C. The binge eating occurs, on average, at least 2 days a week for 6 months.

D. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa.

It's interesting to me how important the "marked distress" feature is. In fact, if you're not feeling this level of distress, but you're still bingeing (even regularly), you wouldn't meet criteria for BED. And, in my interpretation, this includes distress before/during/after a binge, as well as distress about the overall pattern.

In the July issue of O magazine, writer Anne Lamott describes her experience with a a "classic" binge. Having been largely binge-free for 15 years, Lamott recently succumbed first to the allure of a Safeway apple fritter, triggering a no holds barred journey to binge-land. In my opinion, it's not really about her food choices or how much she consumes. I think it's the emotional report that she nails: "I was so lost, and I couldn't follow the bread crumbs back to the path of mental health, because I'd eaten them all. So I ended up eating junk, off and on, until bedtime. . . . It is hard to remember that you are a cherished spiritual being when you're burping up apple fritters and Cheetos."

Interestingly, Lamott describes a critical feature of a binge (beyond quantity and control) that seems, in my mind, just as relevant to the diagnosis: the aftermath. This is an aftermath filled with guilt, shame, self-hatred and sentencing, promises, punishment, and enough of an emotional charge to knock you (as you might want to be) flat-out unconscious. It's an aftermath so uncomfortable that it can, often, only be soothed by more eating, an irony that fuels the cycle and continues the pain.

5 comments:

chrissie said...

What would you say to some one who doesn't feel guilt after a binge?

I don't. I haven't really ever. I know that I know better but I've made a horrible mistake and lost control but I can't let it make me miserable over it (because outside of the binge I am aware of the cycle created by the guilt though I'm not while I'm in the middle of shoveling food into my mouth).

Donna said...

"I was so lost, and I couldn't follow the bread crumbs back to the path of mental health, because I'd eaten them all. "

That really spoke to me. I seems like before I got pregnant I was doing okay (despite being at a complete standstill with weight loss), but I was okay mentally.

After giving birth, I've never been able to attain that same mental place I was back then... I never have found the path back, despite my most honest and sincere efforts.

My binges begin mindlessly... I have to be very conscious of what I put in my mouth. When I do it, I do feel the guilt and make those promises to myself -- I work hard to try each day to treat my self a little better than the last.

littlem said...

Dr. Stacey said:
"It's interesting to me how important the "marked distress" feature is. In fact, if you're not feeling this level of distress, but you're still bingeing (even regularly), you wouldn't meet criteria for BED. And, in my interpretation, this includes distress before/during/after a binge, as well as distress about the overall pattern."

I think this is really important. IMO, the guilt doesn't have to show up nanoseconds after the last crumb. What if you've binged on Monday and Tuesday, but you don't do the disgust/depression/guilt thing until you're desperately attempting to shop for clothes that fit on Saturday?

(I know I might sound flip here, but I get really irritated when people that really need help are left out or don't "qualify" just because they don't meet some stratified criteria. What happened to reliance on the professional judgment of the therapist in question?)

And while I'm on that mini-rant, what about this:

C. The binge eating occurs, on average, at least 2 days a week for 6 months.

The 6 months are REQUIRED to be sequential? So does that mean that if you binge your two days a week for 2 months, and then you're OK for a month, but then you binge again for another 2 months after that, then you're OK for 3 months, but then you binge again for ANOTHER 2 months, you're just fine?

I think the biggest potential omission here might be this one --

3) eating large amounts of food when not feeling physically hungry

because it tends to leave out situations where the binge STARTS because you haven't eaten all day (because you were ashamed to eat in front of other people; because you were so damned busy you ate breakfast at 6am and didn't look up again until 5 that afternoon, or whatever reason), but the person CONTINUES to eat past the point of satiety.

And I'll raise again something I've brought up before -- I know lots of women who binge on cake (and Cheetos), but no one I know binges on carrot sticks.

For the record, when I kicked simple carbs and refined sugar was when I stopped bingeing for good. (Look what happened to Anne Lamott. It wasn't celery that set her off.) I still think there's a chemical element to all this that a lot of researchers are just ignoring.

Dr. Stacey, if you see anything in those notes that seems worth some further thought, by all means please take them back to your APA colleagues so they can be considered in the next draft of "proposed criteria".

I know we're in the age of economically-driven HMO healthcare, where the quicker the diagnosis the more efficient the practitioner is considered to be, but, considering the sheer numbers of women these syndromes tend to affect, perhaps the APA can be a bit more flexible.

drstaceyny said...

Chrissie--I'd say that's a good thing. Adding guilt to the equation is just adding one more difficult emotion (to the already difficult ones that CAUSED the binge). That's great that you're not able to get caught up in the guilt cycle--as those who do feel guilty can probably inform you, the guilt is hurtful and not really useful (it's not like it prevents another binge, typically). I don't think ppl are generally aware of much during a binge--I think it's a lack of awareness that we're pursuing in that moment.

donna--sounds like you're really making an effort. It's interesting how we don't generally have to "work hard" to treat those we love with kindness and consideration, but how it can be an effort for ourselves--future post! : )

m--I could probably write ANOTHER book on the DSM/insurance coverage issues. During grad school, we had a number of lectures and seminars debating the value of the book. It's flawed, certainly, but it does serve a purpose.

Why does it have to be 6 months? I don't know. Because they said so. ; )

But if it's not, the person would probably be diagnosed with EDNOS (keep in mind that BED isn't an actual diagnosis at this point, anyway, so if you meet criteria for BED, you'd technically be classifed as EDNOS). And for the record, it's not just ED's that have these NOS categories: there's Depression NOS, Anxiety NOS, etc. We need to have catch-alls when criteria are too rigid. But, I digress. . .

For your other "what if," I'd say that binges frequently occur following a period of restriction, so there IS a lot of hunger to start. But, somewhere along the line, the hunger is satiated, and you continue to reach for the food--and that's when we're talking abt eating when not physically hungry.

I'm still not convinced that the chemical element is primary in a carbohydrate binge. It may be a factor, but consider these others: To start, cake/Cheetos taste better than carrots, to most ppl. Even for that reason, we're likely to eat more (see theories on positive reinforcement). But, it goes beyond that--cake/Cheetos are "treats," they're (typically since childhood) imprinted on our minds as "forbidden foods," treats we deserve if we're "good." Bingeing on these food as adults is acting out a (healthy) dose of rebellion, as well as enacting your/thoughts and feelings re: what you deserve (from life) in general. It's saying "Screw you" to the ppl and circumstances that haven't given you what you want. You may not have the love, job, companionship, happiness, security, sense of accomplishment you want, but this, this you can have (and you can get it yourself!) Anyone can have a carrot, but YOU deserve a treat.

As for the DSM in general, yes, it's going to leave ppl out (there's no way to include everyone--if there were, it couldn't be categorical). If I saw someone who met all the criteria save for the 6-month bit, I'd still be thinking BED and intervening accordingly. The discrepancy would only really matter (if it did at all) at the reimbursement level (which raises another issue, that these concerns aren't related just to the DSM, but to insurance coverage in general--"Mental Health Parity"--for psychological disorders and EDs in particular).

Edna P said...

Just came across this entry on your blog. What advice would you give to me who meets all the criteria for binge eating? What's my first step to healing? How do I get help?
Thanks