Nearly 30 million Americans have suffered from an eating disorder at some point in their lifetime.
As the following alphabet soup would suggest, the Diagnostic Statistical Manual (DSM) of the American Psychiatric Association (APA) is the diagnostic manual used by mental health professionals in the United States. While it’s necessary for insurance billing purposes and useful in understanding the complexities of a client’s presenting problem so that a treatment plan can be tailored to suit their goals, I like to think of the DSM as simply a big book of human nature.
It’s the kind of book that, should you have the patience to sift through, could give you a heartache and send you running to a therapist, if you didn’t already have one. “That sounds like me!” is a common phrase exclaimed (or whimpered) whenever the book is open. Think WebMD paranoia, but for your emotional aches and pains.
This isn’t a bad thing necessarily; the book is just a book of human nature, which means we’re all described in there at least a few times. What qualifies you for a diagnosis often isn’t if you have these behaviors but if these behaviors have you, which is a matter to be determined between you and your mental health professional.
The official birth of BED
Binge eating disorder (BED) was first introduced in the 5th version of the DSM. Up until 2013, it fell under the umbrella of “eating disorders — NOS (not otherwise specified).” Binge eating disorder joined a category of eating disorders which includes anorexia nervosa, bulimia nervosa, avoidant/restrictive food intake disorder (withholding food but not for the sake of weight loss), pica (eating nonnutritive, nonfood items), and rumination disorder (repeated regurgitation of food).
The prevalence of eating disorders in America is high. The National Eating Disorders Association (NEDA) reports:
In the United States, 20 million women and 10 million men suffer from a clinically significant eating disorder at some time in their life, including Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), or an Other Specified Feeding or Eating Disorder (OSFED).
To illuminate some of the unaddressed nuances of binge eating disorder specifically, I’ll focus briefly on the similarities and differences between anorexia, bulimia, and binge eating disorder.
When I compare the diagnostic criteria for the 3, the most obvious distinctions between them are not methods of practice but rather weight and relationship to body image.
The DSM 5 states that those with anorexia face a disturbance in the way they experience their own body weight or shape, and evaluate themselves under unduly influence of such things. Those with bulimia may also evaluate themselves under unduly influence of body weight or shape but experience their bodies more… accurately. The DSM doesn’t make statements about how those with binge eating disorder experience their bodies or evaluate themselves, and that may be because binge eating disorder is a relatively young official diagnosis, or because the APA doesn’t see any correlation. It could also be because of all 3 of these disorders, the binge eater’s relationship with her body is often the most unconscious, and the DSM isn’t a book meant to explore the unconscious.
Those with anorexia carry an intense fear of gaining weight that will cause them to either withhold food, excessively exercise, or binge and purge to maintain a weight significantly below what their age, sex, and physical health call for. Those with bulimia generally remain at a “normal” or healthy body weight but engage in the same compensatory behaviors in order to achieve it.
Meanwhile, the DSM says those with binge eating disorder simply binge. End of story.
In my experience, those with binge eating disorder can binge, purge, and restrict, but don’t regularly engage in those compensatory behaviors with the specific goal of losing weight, and that may be for reasons not yet delved into within the DSM. These behaviors are important to note because they can be dangerous, even if not done regularly, and they indicate a serious impairment in one’s relationship with a primal survival need.
Not all women with binge eating disorder aim to gain weight. However, for some, the weight is, often begrudgingly, as important as the binge. It’s hard for me to even imagine discussing BED without discussing weight, so it piqued my interest when the DSM overlooked it.
From the perspective of the unconscious (of which, again, the DSM is not particularly concerned), added weight in a society that rejects it can act as a means of rebellion, protection against the predatory male, or as a means of imprisoning oneself in one’s body; a topic worthy of its own exploration.
The depths of the binge
For the binger, a day of restriction can serve as both a means of punishment by way of deprivation, or a celebrated illusory breakthrough in their shame-inducing bingeing habits. Equally double-sided, a purge can feel like a needed exorcism of some internalized toxic self-evaluation, or like paying penance on an earlier binge. But these behaviors are done more sporadically within binge eating disorder because unconsciously, there may be a desire to actually keep the weight.
As such, when someone with BED restricts, the ritual more closely resembles the behavior of someone with avoidant/restrictive food intake disorder in that it isn’t motivated by a permanent disturbance in body image and a willful effort to maintain a low weight. Instead, it may relate more to a negative sensory experience of receiving food into the body; another topic worthy of its own exploration.
The DSM 5 paints BED as sort of a one-dimensional disorder; you binge and there’s not much else to it. And let me be clear; I’m not arguing. The DSM serves a diagnostic purpose only; to provide a clear-cut set of criteria by which to measure up behaviors and determine treatment. It does not serve to uncover the deepest and darkest motivations of a disorder; that’s what the actual work of therapy is for.
It's worth noting that a big book of human nature will always be missing individual or universal nuances as they tend to be rather impossible to capture in any purely scientific way, which is why I aim to help make space for the complexities and motivations and add some color. An eating disorder of any kind can be emotionally painful and physically hazardous; they’re serious illnesses, not lifestyle choices. Yet their prevalence is hard to ignore, and so is our primal need for food, so it seems we ought to keep talking about it.