Beyond Binge-Eating Disorder

I’m frequently asked by journalists and radio and podcast hosts, “How do you define binge eating? How do you know if you’ve got a problem?”

The key diagnostic features of the DSM-5 criteria for binge-eating disorder (BED) are:

• Eats an amount of food much larger than most people would consume in a two-hour window.
• Has the feeling one cannot stop and/or control what or how much one is eating.
• Has marked distress about overeating.
• Absence of regular compensatory behaviors such as purging.
• And the presence of at least three of the following during binge episodes: (a) Eating much more rapidly than normal; (b) Eating until uncomfortably full; (c) Eating large amounts when not physically hungry; (d) Eating alone due to embarrassment; (e) Feeling disgusted or excessively guilty after an episode.

As a psychologist, that’s the answer I’m supposed to give. Most everything else, save for bulimia and anorexia, gets more or less lumped into “Eating Disorder Not Otherwise Specified.” Yet I’m always reluctant to comply because I find out of the hundreds of clients who’ve sought my help due to serious consequences of overeating (e.g., obesity, diabetes, strokes and heart attacks, etc.), only a small portion are formally diagnosable.

The place where I’ve seen the most people in serious trouble fall short of the DSM-5 criteria is that many say they don't experience a lack of control during their overeating episodes, but rather a euphoric release of tension, followed by regret later on. I fear placing these people in the “not otherwise specified” category may provide a false sense of security and prevent them from seeking appropriate care.

Here’s another startling fact to underscore my point:

• The incidence of diagnosed binge-eating disorder hovers between 2% and 3% depending on the study.
• Yet 42.4% of Americans are obese and 73.6% are overweight, according to the National Health and Nutrition Examination Survey as reported by the Centers for Disease Control and Prevention.

Something in these numbers doesn't add up, right? At minimum, we need to acknowledge that it’s possible for habitual overeating to seriously threaten our health even when it doesn’t rise to the level of a diagnosable binge-eating disorder. Do we really want to lump all these people into a “Not Otherwise Specified” category? (Note: I’m omitting bulimia and anorexia from the analysis for simplicity.)

Perhaps the solution is to create a distinct diagnosis for those who meet all other criteria for binge eating except for feeling out of control? Perhaps we could call it “Euphoric Overeating Disorder.” My personal opinion is this would take a lot of the ambiguity out of the Not Otherwise Specified category and cover a significant portion of the troubled eating population. It might be a discrete clinical entity worth studying separate and apart from binge-eating disorder too.

I’d love to know your thoughts in the comments below! If you’re a clinician, how do you diagnose clients who don’t quite rise to the DSM criteria, yet are clearly in serious trouble with their eating? And if you’re a patient who’s been given an “Eating Disorder Not Otherwise Specified” diagnosis, how did that affect your thinking about the problem? I’d be especially interested in hearing from you if you meet the criteria for binge-eating disorder above except for the experience of being out of control.