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Is binge eating a psychiatric disorder?
Rina Silverman's refrigerator is almost always empty. She keeps it that way to avert episodes of frantic food consumption, often at night after a full meal, in which she tastes nothing and feels nothing but can polish off a party-sized bag of chips or a container of ice cream, maybe a whole box of cereal. The food she's eating at these moments hardly matters.
In short order, the nothing that Silverman feels and tastes will give way to nauseating fullness, and a bitter backwash of guilt, shame and self-reproach.
The fullness, in time, passes. But the corrosive shame and self-reproach are always there.
Silverman, a 43-year-old executive assistant from Sherman Oaks, is one of the 145 million Americans who are overweight or obese. But the frenzies of consumption put her in a far smaller category of Americans, not all of whom are even overweight.
Silverman is a binge eater, one who is slowly inching her way toward recovery. She and as many as 1 in 30 Americans -- roughly 7.3 million adults -- are at the center of a psychiatric debate over whether and how to recognize binge eating as a mental disorder.
A decision on the matter is expected early next year, as the American Psychiatric Assn. updates the diagnostic manual that guides the mental health profession.
In light of new research and a seemingly growing population of patients who fit the broad description of binge eaters, psychiatrists must decide whether "binge eating disorder" should stand alongside anorexia nervosa and bulimia nervosa as a separate psychiatric condition -- identifiable by a distinct set of symptoms, a recognizable pattern of progression and a track record of response to certain treatments.
Silverman's symptoms offer a textbook definition of the proposed disorder. Overwhelming feelings of sadness, anger or stress trigger episodes of eating unusually large quantities of food, often when she's not at all hungry. The guilt and shame that follow these episodes sustain her low opinion of herself, and Silverman assumes that her excess weight prompts others to share that opinion. At her lowest points, the binges might occur several times a week, usually at night and away from others' prying eyes. She skips meals and eats erratically in an effort to compensate for her binges.
Overeating may be an American pastime -- and at this time of year, a revered tradition. But a holiday stuffing -- or even the regular practice of eating beyond the point of satiety -- would not qualify as a binge eating disorder.
A 2007 study by researchers at Harvard University-affliated McLean Hospital found, in a national survey of adults, that the set of behaviors widely agreed to define binge eating are present in 3.5% of women at some time in their lives and 2% of men. That would make binge eating a disorder far more common than bulimia and anorexia put together, said Dr. James I. Hudson, lead author of the study.
Many mental health professionals point to those numbers and to the distress that plagues many binge eaters as compelling reasons to recognize this complex of symptoms as a new disorder.
To many skeptics, however, the recognition of binge eating as a psychiatric disorder does nothing but absolve weak-willed people of their responsibility to rein in a dangerous habit. And some suspect that the diagnosis is a sneaky way to sweep an entire nation of overeaters under psychiatry's umbrella -- and possibly into the marketplace for new drugs.
Christopher Lane, author of "Shyness: How Normal Behavior Became a Sickness," says that the formal elevation of binge eating disorder in psychiatry's guidebook would have many unfortunate consequences. Physicians and the public, he said, would quickly recast a behavior that is powerfully rooted in psychological conflicts about food, pleasure and self-image as a brain disorder. "The treatment options then tilt invariably toward medication" over talk therapy aimed at unearthing the behavior's complex underpinnings, he said.
Beyond that, psychiatrists will have to contend with a shortcoming that plagues virtually all of their diagnostic definition: "The cutoff point between normal and pathological" is seldom a sharp line, Lane says. People who binge in response to a difficult life passage could wind up as lifelong patients. And, invariably, many who are overweight but not emotionally hobbled would get a diagnostic label instead of advice to exercise more and eat a bit less.
In short, the specialists involved in the deliberations are picking their way through a minefield of controversies: the causes of a national obesity crisis, personal responsibility versus the medicalization of risky behavior, the nature of addiction and compulsion, even the respective roles of nature and nurture in shaping who we are and how we behave.
"It's a tricky business," says Columbia University psychiatrist B. Timothy Walsh, who chairs the American Psychiatric Assn.'s work group on eating disorders.
"It's easy to oversimplify and criticize" the effort to recognize binge eating as a psychiatric disorder and to assume a diagnosis will be overused by some and misused by others, he adds. "But just because a system can be abused doesn't mean the system is flawed. We have to try to draw lines when we have reasonable confidence we're describing a group of folks who are struggling with impairment."
For Silverman, food has always been a companion, a drug, a form of self-punishment -- providing "protection," she says, from a world that sometimes asks too much of her and seems to give too little in return.
The 50 pounds of extra weight she carries (her actual weight is a tightly held secret) is the first and often only thing that people see, she thinks, and she feels judged -- harshly. The "just do it" weight-loss advice she has gotten from friends and physicians and from the imagined looks of strangers makes her angry, even furious. But she is also complicit in their judgment.
Surely, she often thinks, no one would want to be with a person who looks like her. And rather than shout at a friend or co-worker or rant at a doctor, Silverman said, she'll go home and gorge on her fury, ensuring a new round of self-loathing after a frenzied intake of food.
Experts are converging on the belief that a patient's preoccupation with size -- what Terry Wilson, a Rutgers University psychologist, calls "a dysfunctional concern over weight and shape" -- should be a hallmark of a diagnosis for binge eating disorder. Silverman is a cheerful, smart redhead with pretty brown eyes and a radiant smile. But she has always believed that her weight repels people.
"There are so many things I've stopped myself doing because I'm overweight," says Silverman. " 'When I'm thin, I'll be happy,' I tell myself. My weight serves a purpose for me."
But psychiatrists and psychologists say they must focus on a patient's emotional pain and its effects on day-to-day functioning, not the patient's weight.
When a person stops attending parties for fear she'll embarrass herself with a spasm of eating; when out-of-control eating and the resulting weight gain stop a person from taking a bike ride with his kids or attending a beloved exercise class; when a bout of overconsumption is regularly triggered by anger, stress or sadness, or an unwillingness to acknowledge those feelings, these are cases of impairment and emotional distress that warrant the profession's consideration, Wilson says.
For Silverman, the urgent thoughts can take hold on the way home from a full meal: Chips? Ice cream? Which supermarket to stop at? How soon can I get home?
"It always just felt like I just couldn't control myself. I'd start eating and then couldn't get the food in fast enough," she said.
Says Wilson: "It's not just the food; it's the context in which food is being eaten."
For those debating the status of binge eating, the answer to the "what works?" question is a crucial one -- it defines a disorder by explaining what "recovery" means.
Two kinds of talk therapy have shown good results in stemming or stopping binge eating disorder. One is cognitive behavioral therapy: a relatively short course of psychotherapy designed to help a patient recognize feelings or situations that "trigger" binge behavior and learn reliable ways to minimize them, cope with them or respond to them differently.
The second approach -- thought to be more effective for those with greatest impairment or other psychiatric diagnoses -- is interpersonal therapy, a longer course of talk therapy aimed at exploring complex, unseen motives or childhood traumas that may drive binge eating and other self-destructive behaviors.
Often, those treatments are paired with behavioral weight reduction -- counseling aimed at gradual weight loss and at establishing or returning a patient's erratic eating patterns to a routine of three meals a day and a couple of modest, planned snacks.
Though medications have largely been disappointing in the treatment of binge eaters, a small group of studies has suggested that the diet drug sibutramine (better known by its commercial name, Meridia) and the anticonvulsant drug topiramate (marketed as Topamax) may help curb bingeing behavior.
But effective and lasting weight loss is exceptionally hard. Focusing on it as a goal for the treatment of binge eating has little "clinical utility" because few treatments work, says Walsh.
Wilson adds that it is an ambition likely to doom patients to failure.
"We can stop the binge eating, help patients feel better about themselves, promote greater self-acceptance, reduce depression and improve quality of life," Wilson says. If weight loss is a side effect of treatment, then so much the better, he added. "But we are relatively ineffective at producing weight loss."