Binge eating: How do we distinguish a binge from simply overeating?

by Michael D. Anestis, M.S.

The word "binge" is ubiquitous.  We hear people referring to binges in a variety of contexts with respect to a multitude of behaviors and yet, generally speaking, the precise definition of "binge" remains vague.  Certainly, everyone who uses this term is referencing something large, but that does not leave much room for differentiating between a clinically relevant behavior (e.g., binge eating) and a normative behavior (e.g., Thanksgiving dinner). The purpose of today's article is to provide some clarity on this topic, with a particular focus on the definition and nature of binge eating.
According to the DSM-IV-TR, a binge eating episode has two defining characteristics.  The first is that more food is consumed in a discrete period of time than would typically be consumed by others in that same period within the same context.  A discrete period of time is, admittedly, a fairly broad term, although the DSM further specifies that a single episode should last less than two hours.  The second defining characteristic is that the individual experiences a perceived loss of control during the episode.  Having spent a significant amount of time discussing the nature of binge eating with both clients and students, I have found that a fairly distinct pattern of questions almost invariably emerges.  As such, I would like to address several of these questions here.

Why does the DSM specify the need to consider context?  Isn't a binge a binge regardless of where or when it happens?

    A binge is, indeed, a binge, but context is nonetheless important to consider.  One way to think about this, as alluded to above, would be to consider holiday meals.  Most of us consume a considerably above average amount of food during Thanksgiving dinner.  This, however, does not necessarily represent a binge because, contextually, it is a normative behavior.  Thanksgiving dinner is a ritualized, culturally-bound phenomenon that encourages excess in one particular instance.  This is not to say that Thanksgiving dinner can not still represent overeating; however, as my answers to subsequent questions will help clarify, overeating and binge eating are distinct from one another.  An individual can binge during Thanksgiving dinner if they meet all of the binge criteria, but simply eating a lot on Thanksgiving does not necessarily qualify as binge eating.

I've done this before.  Does that mean I have an eating disorder?

    Absolutely not.  To meet criteria for bulimia nervosa (BN) or binge eating disorder (BED), the DSM-IV-TR requires that the binges occur, on average, twice per week for a period of no less than three months. It is not at all uncommon for an individual to report that they have experienced one ore more binge episodes in their lifetime.  For this to have clinical significance, however, it needs to be a recurrent pattern that causes distress and dysfunction in the individual's life.  If an individual "tried out" the behavior in response to social pressure, body dissatisfaction, a mood disorder, or any other prompting event but did not continue, that individual would not meet criteria for BN or BED.  If the binges are infrequent but cause distress and/or impairment, a clinician may consider a diagnosis of eating disorder not otherwise specified (EDNOS), but this is an unlikely presentation.

What do you mean, loss of control?  Can't people just stop eating when they want to?

A key point here is that the loss of control is perceived by the individual.  Yes, it is always physically possible to stop eating, but a variety of individuals are predisposed to under controlled, dysregulated behaviors.  I've had clients who binge eat explain to me that, when they started a binge, it felt as though a wave was coming towards them and they could do nothing to stop it from crashing ashore.  This perceived lack of control can be conceptualized as a difficulty inhibiting behaviors.  Essentially, for folks who binge eat, it is as though they are driving a car and their brake pedal is faulty - so they are not necessarily speeding towards the binge, but they struggle to stop the event from happening once they are in motion.  A variety of characteristics have been shown to predict who is vulnerable to developing patterns of under controlled eating, including high levels of negative urgency (which we will discuss in detail in future posts) and low levels of distress tolerance (Anestis, Selby, & Joiner, 2007; Anestis, Selby, Fink, & Joiner, 2007; Fischer, Anderson, & Smith, 2004).
    The perceived loss of control is important to consider when attempting to distinguish between clinically relevant binge eating and normative eating experiences.  When I go to Cheeburger Cheeburger on Sanibel Island, Florida, I often decide to order the one pound burger so as to get my picture placed on the wall.  This behavior is thus planned ahead of time and represents a careful decision on my part.  The premeditated nature of the behavior, in part, serves to disqualify this meal as a binge.  Even more so, however, my ability to stop when I feel full is what makes this particular meal not fit the category of binge eating.  When the burger is too much - which happens from time to time - I simply stop.  I do not feel compelled to continue.  When an individual binge eats, she often feels as though the behavior is simply happening, almost as though she is a spectator with no control over the outcome.

A spectator?  What could that possibly mean?

    A very legitimate question.  How can an individual be a spectator to their own behavior?  In reality, this does not mean the individual is watching the behavior take place as though it was occurring on television.  Instead, it refers to dissociation.  We will write in more detail on dissociation in future posts, but for the sake of clarity, I will provide a brief description here.  Dissociation is a state of mind in which individuals feel disconnected from and often do not attend to their immediate environments.  We all do this from time to time.  Have you ever been driving and realized that you do not remember the past five minutes of your trip?  Have you ever been in a conversation and suddenly realized that your mind had wandered elsewhere and you have no idea what the other individual is saying?  These are mild examples of dissociation.  For some individuals, stress can induce a more troubling form of dissociation, in which what is happening feels unreal, almost as though it was a dream.
    For individuals who binge eat, dissociation is a common experience.  As such, they do not savor the food they are eating, enjoy the experience as it is happening, or feel capable of enacting any degree of control over the behavior. In earlier posts discussing dialectical behavior therapy (DBT), we mentioned that there is compelling empirical evidence that DBT is an effective treatment for bulimia nervosa (BN) and binge eating disorder (BED), both of which are characterized by frequent binge eating.  One explanation for this might be the emphasis on mindfulness, which teaches individuals skills for remaining focused on neutral present stimuli and can help prevent or diminish dissociative experiences.

What if somebody says they binge eat but they actually do not eat large quantities of food?

    This is a very common phenomenon.  As such, clinicians are taught to differentiate between objective and subjective binge episodes.  Objective binge episodes meet the criteria detailed above.  Subjective binge episodes, on the other hand, involve perceptions on the part of individuals that they binge ate when, in fact, they did not eat enough food to qualify for an objective binge.  Oftentimes, individuals who have eating disorder or who are dieting have a "banned foods" list.  For some individuals, eating even a single item off of this list constitutes a binge, regardless of the caloric intake.  Interestingly, there is some evidence that the perceived lack of control is more important than the actual size of the episode and that, while it is important to distinguish between objective and subjective binges in order to ensure accurate perceptions of the impact of consuming particular foods, subjective binges are equally problematic (Keel, Mayer, & Harnden-Fischer, 2001).

What disorders are characterized by binge eating?

    Binge eating disorder (BED) is a disorder characterized by binges that occur, on average, at least twice per week for a period of no less than three months.  Individuals with BED do not engage in compensatory behaviors aimed at counteracting binge eating episodes (e.g., self-induced vomiting, abuse of laxatives, excessive exercise).  Bulimia nervosa (BN) is a disorder characterized both by recurrent binge eating episodes (same frequency requirement as BED) as well as compensatory behaviors aimed at counteracting the effects of a binge.  Anorexia nervosa (AN) includes two subtypes.  The first, restrictive type, does not involve regular binge eating.  The second, however, is referred to as binge-eating/purging type and does involve regular binge eating.  The difference between binge-eating/purging type AN and BN is that individuals who meet criteria for the former are severely underweight whereas individuals who meet criteria for BN are typically of normal weight.
    Importantly, although eating disorders are significantly more common in women than in men, there is evidence that there are no sex differences in rates of binge eating behaviors (Striegel-Moore & Franko, 2003).

Is there really any difference between obese individuals without an eating disorder and obese individuals with binge eating disorder?

    Wilfley, Wilson, and Agras (2003) provide a thorough review on this topic.  Obese individuals with BED consume more calories during binge episodes and non-binge meals than do weight-matched individuals without an eating disorder (Yanovski, 2002).  Additionally, obese individuals who meet criteria for BED are three times more likely than obese individuals without an eating disorder to meet criteria for depression (Telch & Stice, 1998).  As such, a classification of binge eating disorder is not simply putting a label on being obese.  Instead, it is calling attention to a distinct subset of individuals who are particularly vulnerable to a variety of problematic outcomes.

What prompts individuals to binge eat?

    There are a variety of things that can cause an individual to binge eat, but one of the most well supported precipitating factors is negative affect.  Several studies have shown that binge episodes are typically preceded by highly negative moods.  Additionally, although not universally supported, some studies indicate that, in addition to being preceded by states of negative affect, binge eating episodes are followed by immediate reductions in negative affect, which reinforces the use of the behavior (Smyth et al., 2007).  So, although not all binge episodes are prompted by negative moods, it appears that emotions play a pivotal role, which explains why interventions such as DBT, which teach emotion regulation skills, have shown such strong results. 

How do individuals who binge eat feel about their behavior?

    It is important to consider this question.  Typically, individuals who struggle with binge eating are highly ashamed of their behaviors.  They binge eat in secrecy and avoid social situations that might involve eating.  In treatment, clinicians sometimes struggle to motivate the client to involve peers and/or family as a support system because the client feels such shame.  Clients who binge eat often feel like a "freak," so it is important to educate them on how common this behavior is and to demonstrate that there is no evidence supporting their belief that peers and family will refuse to help.


There are many other questions that come up when I talk about binge eating with clients and students.  Can you think of others?  Are there answers to these questions that you think I may have overlooked in this article?  I encourage you to share your thoughts with other readers through the comment section.  Ideally, I would love for this to be a conversation involving a variety of perspectives and experiences.  I can think of no better way to encourage a broad, thorough education on this important topic.

If you would like to learn more about binge eating, we encourage you to explore the following resources, all of which are available through the Psychotherapy Brown Bag online store:

Books:

• Crave: Why You Binge Eat and How to Stop

• Overcoming Binge Eating

• Overcoming Your Eating Disorder: A Cognitive-Behavioral Therapy Approach for Bulimia Nervosa and Binge-Eating Disorder, Guided Self Help Workbook (Treatments That Work)

• Dialectical Behavior Therapy for Binge Eating and Bulimia

• Overcoming Eating Disorders: A Cognitive-Behavioral Therapy Approach for Bulimia Nervosa and Binge-Eating Disorder Therapist Guide (Treatments That Work)

• Binge Eating: Nature, Assessment, and Treatment

• Binge-Eating Disorder: Clinical Foundations and Treatment

Kindle:

• Overcoming Your Eating Disorder: A Cognitive-Behavioral Therapy Approach for Bulimia Nervosa and Binge-Eating Disorder, Guided Self Help Workbook

• Binge-Eating Disorder: Clinical Foundations and Treatment

• Eating Disorders, Anorexia, Bulimia, Causes, Symptoms, Signs, Diagnosis and Treatments

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.