This article discusses the relationship between substance use disorders and binge eating disorder. The diagnosis of an eating disorder requires expert training and certification in understanding behavioral assessment. The information in this article is designed to be used for educational purposes only and cannot be used to diagnose anyone with any type of mental health issue. Only licensed mental health professionals can make these diagnoses.
Normalcy vs. Disordered Behaviors
An eating disorder must be diagnosed based on the person’s behavior and the ramifications of that behavior. Individuals who overeat and are overweight may not have formal eating disorders, but may have issues with self-control that need to be addressed. The difference between an eating disorder and simple overeating can often be based on a fuzzy boundary; however, the difference between the two is based on both qualitative and quantitative differences in the behavior. A large number of individuals in the United States are overweight and obviously eat too much food and get too little exercise; however, it would be wrong to diagnose such a large group of individuals with a formal mental health disorder similar to the notion that a large number of individuals most likely do not always tell the truth and often exaggerate issues, but it would be wrong to state that all these individuals are “compulsive liars.”
One criticism of mainstream psychiatry is that it tends to pathologize many types of behaviors that really occur within the realm of normal experiences. Thus, it is very important to define what is considered to be a disorder versus what is considered to be within the realm of normal functioning. This is especially relevant when discussing eating disorders.
While certain behaviors are considered to be disordered, certain similar expressions of these behaviors are also considered to be relatively common within certain contexts. For example, becoming angry is a relatively common occurrence that individuals express in a number of different contexts; however, becoming extremely angry in certain contexts or nearly always expressing anger in certain manners (e.g., constantly using physical aggression, degrading people, long tirades, etc.) is considered to be inappropriate. Likewise, the notion of a behavioral disorder or a psychiatric/psychological disorder is considered to occur in the following situations:
- The behavior is considered to be very extreme.
- The behavior occurs across many different contexts and considered to be extreme within all of these or most of these contexts.
- The behavior is relatively unchangeable over many different contexts even in contexts where it is not appropriate.
- The behavior results in negative consequences for the person that can include issues with their physical health, emotional functioning, relationships, work, and other aspects of their lives.
- Despite having serious negative consequences for the person, the individual continues to engage in the behavior.
- Often, individuals try to control their behavior because of the negative consequences it produces for them, but they are unable to do so.
Behaviors that are considered to be within normal limits are characterized by quite a bit of variability. Behaviors that are considered to be disordered are characterized by a more constricted range with some rather fuzzy boundaries. Because there are no formal medical tests that can identify the presence of the vast majority of psychiatric/psychological disorders, such as can be done for physical diseases like cancer, heart disease, etc., these disorders admittedly require some bit of subjectivity in their diagnosis. In cases where they are extreme, the diagnosis is relatively easy to make, whereas in cases where they may be vague, the clinician must often make a judgment based on what is best for the individual and on the clinician’s experience and training.
Moreover, many psychological/psychiatric disorders develop over time. There are no formal diagnostic criteria that can reliably predict whether one individual is on the road to developing a formal psychological/psychiatric disorder and another is not.
What Is a Binge Eating Disorder?
The notion of a binge eating disorder (often abbreviated as BED) is diagnosed when an individual displays multiple episodes of binge eating that must occur an average of one time per week over a three-month period. The notion of binge eating refers to eating a large amount of food over a particular timespan that is markedly and obviously larger than most people would eat over a similar timespan and under very similar conditions. This means that the context of the individual’s eating behaviors plays a role in determining what a binge eating episode may be. There is obviously some subjectivity regarding the determination of what is a significantly large amount of food consumed in that particular context and timespan.
The binge eating disorder can only be diagnosed when the individual:
- Eats in this manner on average at least once a week for a period of at least three months
- Consumes significantly more food than most people would eat in similar circumstances in a similar timespan
- Has an experience of a lack of control during the binge eating episode
The binging episodes must meet three of the above five criteria for binge eating, and the individual must experience marked distress regarding their behavior.
While there is still some subjectivity regarding the diagnosis of BED, the criteria are designed to make the specifications regarding the disorder as targeted and specific as possible given the lack of biological or objective tests to diagnose eating disorders. In addition, individuals can be diagnosed with mild, moderate, severe, or extreme presentations of BED, depending on the number of weekly binging episodes they engage in. Obviously, individuals who are diagnosed with severe or extreme BED represent serious manifestations of the disorder.
Binge eating behavior occurs in other psychiatric/psychological disorders, such as bulimia. When an individual’s behavior can be better explained by the presence of another psychiatric/psychological disorder, a medical condition (e.g., certain types of head injuries produce impulsive eating behaviors), or the use of drugs or medications, a binge eating disorder is not diagnosed.
The designations oF BED:
- Mild BED is diagnosed when there are 1-3 binges per week.
- Moderate BED is diagnosed when there are 4-7 binges per week.
- Severe BED would be diagnosed when there are 8-13 binges per week.
- Extreme BED is diagnosed when there are more than 13 binges per week.
How BED Relates to Substance Use Disorders
According to Kaplan and Sadock’s Synopsis of Psychiatry, BED is diagnosed twice as often in females than it is in males. The disorder appears to occur in equal distributions across different ethnic groups; however, it is more often diagnosed in younger individuals below the age of 30 than in individuals who are above that age.
As would be expected, BED is more commonly diagnosed in individuals who are overweight or considered to be obese and seeking treatment for their weight issue, but it can occur in individuals who are of normal weight as well. In addition, the majority of people who would qualify as obese based on clinical standards do not meet the formal diagnostic criteria for binge eating disorder. BED appears to occur in about 2 percent of the population and in about 8 percent of individuals who are clinically obese.
Individuals diagnosed with BED appear particularly vulnerable to developing substance use disorders with stimulant medications, diet aids that contain stimulants, and other amphetamines due to taking these substances as diet aids. Individuals with BED also appear to be susceptible to developing alcohol use disorders.
An issue that has been investigated in research is the link between eating disorders and issues with impulse control. At one time, eating disorders were thought to be primarily disorders of impulse control. People who have issues with binge eating are often more susceptible to environmental cues that stimulate appetite or eating behaviors, such as the smell of food, pictures of food, or even seeing food. People with BED may be more susceptible to eating behaviors as a result of these forms of stimulation even if they are not hungry, which has led to the notion that there is an important link between impulse control and binge eating behavior.
The research suggests that BED and even other eating disorders may be linked to particular issues with controlling behavior regarding issues with food, and not with having the same issues with monitoring behavior and impulse control with other forms of behavior. However, there are no formal causes identified for any form of eating disorder. The current understanding of these disorders suggests that certain genetic associations, life experiences, and other environmental cues interact to produce these behaviors in individuals who are diagnosed with these disorders.
Treatment Issues
BED appears to be a little more complicated than the diagnostic scheme indicates. Research into BED suggests that there are two subtypes to the disorder: one subtype that primarily engages in binge eating alone and another subtype that engages in binge eating but also has other comorbid (co-occurring) psychological/psychiatric disorders. The approach to treatment should be based on a thorough assessment of the individual’s presentation in order to identify any comorbid psychological issues that also need to be addressed. If the individual is not treated as an entire person, and all of the relevant issues or diagnoses are not considered, the treatment has a far less chance of being successful.
In some cases, antidepressants (selective serotonin reuptake inhibitors) and other medications may be prescribed for individuals with BED.
However, it should be noted that medication use alone does not address the issues that individuals with BED suffer from, and that the use of some form of therapy is considered to be the preferred form of treatment for these individuals.
Most often, some form of Cognitive Behavioral Therapy (CBT) addresses the person’s belief system and attitudes toward food and eating in general. The therapy then challenges these and helps the individual to change them.
In addition, individuals who are overweight or obese and suffer from BED often benefit from CBT, weight loss programs, and even medications used in conjunction. If the individual has a comorbid psychological/psychiatric condition, this should also be addressed in an appropriate manner in order for the treatment to be successful.
The treatment of BED and co-occurring substance use disorders should focus on treating both disorders at the same time. This would include targeted interventions for the substance use disorder. The use of withdrawal management and medically assisted treatment for substance abuse (if required), targeted therapy for substance abuse, and social support and support group participation would need to be implemented in conjunction with treatment for BED. Like any substance use disorder treatment program, the individual should engage in long-term aftercare for the treatment of their substance abuse and their BED in order to ensure continued recovery.