David Baxter PhD
Late Founder
Eating Disorder Patients Lose When Playing the Diagnosis Game
In my practice as a psychologist and psychoanalyst I've worked with hundreds of patients struggling to resolve their eating disorders. Over the last few weeks I have been bombarded with questions regarding the New York Times article about binge eating. Some want to know which disorder they have and even if they qualify for a diagnosis at all. One complained bitterly that she is not a bulimic because she doesn't purge and given the intense snobbery among the eating disorder patients she was adamant about not being included in ?that? group.
?I?m not sick, they are,? she said.
Another patient wanted to know, ?What is the point of the different diagnosis at all?? And still others want to know what the difference is in the treatment. I have been in the field for over thirty years and questions like these always give me pause and make me return to the basics. They make me think and rethink material that I solved and re-solved during my training years ago.
The original binge eating article from the Times emanated from a Harvard study covered earlier on this blog, that surveyed almost 3000 men and women to ascertain the rates of different disordered eating behaviors. They found that almost 3% of respondents were ?binge eaters? or had been binge eaters in the past. That was almost double the number who reported anorexia and bulimia nervosa combined. The article defined binge eating as ?eating an excessively large amount of food in a 2 hour period at least twice a week for 6 months, feel[ing] a lack of control over the episode and experienc[ing] marked distress regarding the practice?.
While I'm not quibbling with their numbers, this study and the rash of media attention that has followed in its wake, highlights a particularly difficult problem that arises for clinicians every so often: that of identifying or refining a diagnosis. Up to now ?binge eating? has not been identified as a separate and distinct diagnosis by the clinician?s bible, the American Psychiatric Association published Diagnostic and Statistical Manual IV (DSM IV). Prior to this intense scrutiny most therapist, if they saw patients presenting with these symptoms, lumped them in with other bulimics.
In order to make a diagnosis of bulimia the DSM IV requires that following conditions should be met (emphasis mine):
The media, constantly preoccupied with sound bites, has confused the public into believing that bulimia nervosa always culminates in vomiting. On the basis of the above definition this is clearly not the case. Bulimics, after the binge, can have a whole host of behaviors including the use of laxatives, diuretics, enemas, over-exercise and fasting. Bulimics are also always on the look out for ?new and improved? techniques for handling their binges.
Recently, a newer patient proudly revealed that although she was a bulimic for years, she no longer felt compelled to purge and was thrilled that she was ?past all that disgusting behavior.? When I asked her what was she doing to control her weight now, since she looked great, she sheepishly told me, ?I spit. I chew my food and then spit it in a cup so I don't swallow it and find it on my hips the next day?.
She?s not alone. Other patients have described eating in restaurants and using their napkins as a receptacle. They take pride in having mastered the fine art of bringing the napkin to their mouths as if to blot their lips, and instead surreptitiously depositing chewed food.
Another patient claimed emphatically she was an anorexic who binged but did not purge. She said she had been hospitalized twice in her late teens for anorexia. When she revealed that she was only 5?3 and 94 lbs, I told her I was surprised that they had admitted her given she was not in any medical distress. She said that her mother insisted that she was an anorexic not bulimic because she didn?t purge and ?being a bulimic is disgusting. Proper, lady-like girls are anorexic.?
Others think that because they use ipecac or have trained their muscles to induce a purge at will then they aren?t really bulimics. Over exercisers and excessive dieters, always looking for panaceas for their binging behavior, often refuse to see themselves as bulimics. They are horrified to learn that they have a disordered relationship with food and meet the criterion for bulimia nervosa.
As with anyone who is obsessed?be it with food, drugs, alcohol, sex or the like?until the behavior has serious consequences, they are not likely to accept that they have a problem. People loathe giving up what has worked for them and try something new. They function in a quasi-denial mode using any defense or excuse to justify their behavior and avoid the anxiety of change. Eating disorder patients bring a whole new meaning to avoidance of their reality.
The diagnosis of anorexia nervosa is in sharp contrast to bulimia nervosa. It focuses strictly on food restriction and the number of calories introduced into the body. Anorexia requires a refusal to maintain at least 85% of normal body weight and a distinctly distorted view of one?s weight or body shape. Bingeing is not part of the behavioral syndrome at all. Once the bingeing starts, the diagnosis almost immediately changes from anorexia to bulimia.
The Harvard study claims to have identified a large, distinct group of psychologically disturbed patients that require treatment not here to fore diagnosable under either of the established eating disorder classifications. This study has encouraged serious consideration of the creation of a third diagnostic criterion for eating disorders that would include binge eating alongside the established diagnoses. The claim is that this third group binge eats but does not purge or use any compensatory behavior nor do they starve, and therefore under the current definition can not be classified under the DSM IV as disordered eaters.
One might wonder why we need diagnoses in the first place. Generally, diagnoses serve as a definition for clients, who can often benefit from having a word to address their problem and let them know that they are not alone or untreatable. At another level, these semantic games are important for purposes of correctly billing the insurance companies. Without a diagnosis patients can?t receive reimbursable psychological treatment. But the diagnostic manual was created long before the insurance companies got involved in making money in mental health care.
Diagnoses serve a number of other purposes though. They are shorthand for professionals, allowing for the sharing of information in a concise and precise manner. Aside from specifics, diagnoses serve the important function of accessing a huge body of knowledge accumulated by other professionals? research and study regarding expected course, length of treatment, treatment options and results. Diagnosis is also invaluable in research, as it allows populations to be sorted out, identified, replicated, compared and contrasted. How can you do a study on bulimics if you are not using the same criterion for what constitutes bulimia?
Creating a new classification or altering an old one is a big deal. But, the DSM must change with the times if it is to be viable. Since I don?t do research and can only speak anecdotally from treating a population of five or six hundred eating disorder patients over the last 30 years, I have to ask myself if there is a significant enough difference between bulimics and binge eaters to justify the addition of a new diagnosis. Or can they in fact be lumped together for the purpose of treatment? Do I really treat a patient who binges differently than I treat one who binges and uses some sort of compensatory behavior? Do I see their behavior as pathologically distinct? Is the etiology that different? Inside my clinical office, playing diagnosis games often serves only to distract from the task at hand, treating an individual with serious problems.
What I have discovered is that there is a tremendous amount of crossover in eating disorders. Many patients start out as anorexics and then become bulimics. Over long periods of time this can go back and forth, but in my experience the anorexic usually becomes a bulimic and not the other way around. Bulimics can be thin, normal weight or obese and can go back and forth over the years. Many patients stay in the bulimic mode for the rest of their lives using new and innovative tricks to avoid gaining weight. Others can overcome their issues, stop binging and lead normal lives. And yet others are in and out of therapy for the rest of their lives trying to conquer their obsession and control issues and go in and out of hospitalization. Some clients never recover, and eventually die.
What I do know, and what logic dictates, is that a patient who is binge eating is going to be obese if the behavior continues unchecked in some way. Consuming a massive amount of calories is going to put on the pounds. In the DSM IV there is no specific diagnosis for obesity because many obese people live psychologically unfettered lives, they just eat too much or have physical limitations. Obesity is a strictly medical diagnosis based on body mass index, along with other factors, unless it interferes with the healthy psychic function of the patient. It is important not to confuse eating disorder with overweight. Being overweight does not mean you binge it means you intake more than you put out.
Overeating is not bulimia. The bulimic binge is very specific. It is done with premeditation, usually involving an elaborate plan. As one patient's story makes clear, in most cases the planning is the real indulgence.
?At my desk I?d plot and plan just exactly what I was going to binge on? Butter pecan ice cream, a large shake, a box of Oreo cookies, jelly beans, those wonderful sugar wafers?.etc,? a patient told me, describing her own elaborate scheme. ?I plotted what stores I would buy it in so they wouldn?t get suspicious and realize what I was doing."
She continued: "If the check out clerk said anything I had my rap all prepared. 'It's my kids birthday party.' I don?t even have a kid. All day I would wait till 6:00 o'clock. I'd run out of the office in a trance, like I was going to meet my lover. Trying to look casual and in control I would do my shopping, race home with my 'sacred stash' and start devouring everything. Just eating and eating in a sort of zone. Eating long after any pangs of hunger. In fact hunger had nothing to do with it. It wasn't in the equation. Despite being full I just don't stop. Then the coma would come over me and I would sort of pass out. Sometimes I'd come to and start all over again making another pit stop at the local grocery. Eventually I'd feel sick and bloated and terrible and every so guilty and bad."
At this point the bulimic either vomits or makes a pact with herself to exercise for four hours or starve for two days or whatever it takes to repent?always promising to quit the behavior just like a drug addict.
Let's face it: these situations are all bad. They all involve sick, abnormal and unhealthy behavior, which is why they are diagnosable disorders in the first place. But playing the game of obscuring the illness by creating different diagnoses is really not going to make anyone better. All eating disorder patients are suffering from conflicts that are being played out on the field of food.
From my experience with them, they are only too happy to downplay their illness by denying it. Having the ability to use a catch phrase like binge eating instead of the better-known and serious sounding diagnosis of bulimia nervosa will only encourage them to minimize their disorder. Whether the diagnosis is anorexia, bulimia, or even the as of yet unclassified binge eating disorder, call them what you will, one way or another these patients are obsessed with control and they are all focusing their attention on food and body image as a technique for avoiding the major challenges of life.
To truly treat patients with eating disorders it is far, far less important to assess the various ways they play out their disordered relationships with food, and far, far more important to focus attention on the purpose of their unhealthy behavior. Working in the clinicians? office or wherever treatment can happen, the therapist must help the client realize that their obsession with food is a distraction from the challenges of life. As long as they escape by focusing on the morsels they eat or the binges they go on, they spend less time focusing on their love life, their career, their family and their expectations. If they continue to avoid their life and keep their focus on their unhealthy relationships with food, it eventually will lead to dangerous and potentially deadly results.
We should soon start hearing news about the forthcoming update to the DSM, and if this surge in news coverage regarding binge eating is any indication, we might very well see changes in how we diagnose disordered eating. It is important though that we don?t lose sight of the real issue here, which is the health of clients. By playing the diagnosis game, and allowing them to play it, we only serve to further enable them to pass the buck and hide from the real issues in their lives that are making them sick. Diagnoses are important, but should be secondary to making sure that each patient makes progress toward a healthy life.
In my practice as a psychologist and psychoanalyst I've worked with hundreds of patients struggling to resolve their eating disorders. Over the last few weeks I have been bombarded with questions regarding the New York Times article about binge eating. Some want to know which disorder they have and even if they qualify for a diagnosis at all. One complained bitterly that she is not a bulimic because she doesn't purge and given the intense snobbery among the eating disorder patients she was adamant about not being included in ?that? group.
?I?m not sick, they are,? she said.
Another patient wanted to know, ?What is the point of the different diagnosis at all?? And still others want to know what the difference is in the treatment. I have been in the field for over thirty years and questions like these always give me pause and make me return to the basics. They make me think and rethink material that I solved and re-solved during my training years ago.
The original binge eating article from the Times emanated from a Harvard study covered earlier on this blog, that surveyed almost 3000 men and women to ascertain the rates of different disordered eating behaviors. They found that almost 3% of respondents were ?binge eaters? or had been binge eaters in the past. That was almost double the number who reported anorexia and bulimia nervosa combined. The article defined binge eating as ?eating an excessively large amount of food in a 2 hour period at least twice a week for 6 months, feel[ing] a lack of control over the episode and experienc[ing] marked distress regarding the practice?.
While I'm not quibbling with their numbers, this study and the rash of media attention that has followed in its wake, highlights a particularly difficult problem that arises for clinicians every so often: that of identifying or refining a diagnosis. Up to now ?binge eating? has not been identified as a separate and distinct diagnosis by the clinician?s bible, the American Psychiatric Association published Diagnostic and Statistical Manual IV (DSM IV). Prior to this intense scrutiny most therapist, if they saw patients presenting with these symptoms, lumped them in with other bulimics.
In order to make a diagnosis of bulimia the DSM IV requires that following conditions should be met (emphasis mine):
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- a. Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
- b. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
- a. Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
- Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise.
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months.
- Self-evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during episodes of anorexia nervosa.
- Purging type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxative, diuretics, or enemas.
- Non-purging type: during the current episode of Bulimia Nervosa, the person used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
The media, constantly preoccupied with sound bites, has confused the public into believing that bulimia nervosa always culminates in vomiting. On the basis of the above definition this is clearly not the case. Bulimics, after the binge, can have a whole host of behaviors including the use of laxatives, diuretics, enemas, over-exercise and fasting. Bulimics are also always on the look out for ?new and improved? techniques for handling their binges.
Recently, a newer patient proudly revealed that although she was a bulimic for years, she no longer felt compelled to purge and was thrilled that she was ?past all that disgusting behavior.? When I asked her what was she doing to control her weight now, since she looked great, she sheepishly told me, ?I spit. I chew my food and then spit it in a cup so I don't swallow it and find it on my hips the next day?.
She?s not alone. Other patients have described eating in restaurants and using their napkins as a receptacle. They take pride in having mastered the fine art of bringing the napkin to their mouths as if to blot their lips, and instead surreptitiously depositing chewed food.
Another patient claimed emphatically she was an anorexic who binged but did not purge. She said she had been hospitalized twice in her late teens for anorexia. When she revealed that she was only 5?3 and 94 lbs, I told her I was surprised that they had admitted her given she was not in any medical distress. She said that her mother insisted that she was an anorexic not bulimic because she didn?t purge and ?being a bulimic is disgusting. Proper, lady-like girls are anorexic.?
Others think that because they use ipecac or have trained their muscles to induce a purge at will then they aren?t really bulimics. Over exercisers and excessive dieters, always looking for panaceas for their binging behavior, often refuse to see themselves as bulimics. They are horrified to learn that they have a disordered relationship with food and meet the criterion for bulimia nervosa.
As with anyone who is obsessed?be it with food, drugs, alcohol, sex or the like?until the behavior has serious consequences, they are not likely to accept that they have a problem. People loathe giving up what has worked for them and try something new. They function in a quasi-denial mode using any defense or excuse to justify their behavior and avoid the anxiety of change. Eating disorder patients bring a whole new meaning to avoidance of their reality.
The diagnosis of anorexia nervosa is in sharp contrast to bulimia nervosa. It focuses strictly on food restriction and the number of calories introduced into the body. Anorexia requires a refusal to maintain at least 85% of normal body weight and a distinctly distorted view of one?s weight or body shape. Bingeing is not part of the behavioral syndrome at all. Once the bingeing starts, the diagnosis almost immediately changes from anorexia to bulimia.
The Harvard study claims to have identified a large, distinct group of psychologically disturbed patients that require treatment not here to fore diagnosable under either of the established eating disorder classifications. This study has encouraged serious consideration of the creation of a third diagnostic criterion for eating disorders that would include binge eating alongside the established diagnoses. The claim is that this third group binge eats but does not purge or use any compensatory behavior nor do they starve, and therefore under the current definition can not be classified under the DSM IV as disordered eaters.
One might wonder why we need diagnoses in the first place. Generally, diagnoses serve as a definition for clients, who can often benefit from having a word to address their problem and let them know that they are not alone or untreatable. At another level, these semantic games are important for purposes of correctly billing the insurance companies. Without a diagnosis patients can?t receive reimbursable psychological treatment. But the diagnostic manual was created long before the insurance companies got involved in making money in mental health care.
Diagnoses serve a number of other purposes though. They are shorthand for professionals, allowing for the sharing of information in a concise and precise manner. Aside from specifics, diagnoses serve the important function of accessing a huge body of knowledge accumulated by other professionals? research and study regarding expected course, length of treatment, treatment options and results. Diagnosis is also invaluable in research, as it allows populations to be sorted out, identified, replicated, compared and contrasted. How can you do a study on bulimics if you are not using the same criterion for what constitutes bulimia?
Creating a new classification or altering an old one is a big deal. But, the DSM must change with the times if it is to be viable. Since I don?t do research and can only speak anecdotally from treating a population of five or six hundred eating disorder patients over the last 30 years, I have to ask myself if there is a significant enough difference between bulimics and binge eaters to justify the addition of a new diagnosis. Or can they in fact be lumped together for the purpose of treatment? Do I really treat a patient who binges differently than I treat one who binges and uses some sort of compensatory behavior? Do I see their behavior as pathologically distinct? Is the etiology that different? Inside my clinical office, playing diagnosis games often serves only to distract from the task at hand, treating an individual with serious problems.
What I have discovered is that there is a tremendous amount of crossover in eating disorders. Many patients start out as anorexics and then become bulimics. Over long periods of time this can go back and forth, but in my experience the anorexic usually becomes a bulimic and not the other way around. Bulimics can be thin, normal weight or obese and can go back and forth over the years. Many patients stay in the bulimic mode for the rest of their lives using new and innovative tricks to avoid gaining weight. Others can overcome their issues, stop binging and lead normal lives. And yet others are in and out of therapy for the rest of their lives trying to conquer their obsession and control issues and go in and out of hospitalization. Some clients never recover, and eventually die.
What I do know, and what logic dictates, is that a patient who is binge eating is going to be obese if the behavior continues unchecked in some way. Consuming a massive amount of calories is going to put on the pounds. In the DSM IV there is no specific diagnosis for obesity because many obese people live psychologically unfettered lives, they just eat too much or have physical limitations. Obesity is a strictly medical diagnosis based on body mass index, along with other factors, unless it interferes with the healthy psychic function of the patient. It is important not to confuse eating disorder with overweight. Being overweight does not mean you binge it means you intake more than you put out.
Overeating is not bulimia. The bulimic binge is very specific. It is done with premeditation, usually involving an elaborate plan. As one patient's story makes clear, in most cases the planning is the real indulgence.
?At my desk I?d plot and plan just exactly what I was going to binge on? Butter pecan ice cream, a large shake, a box of Oreo cookies, jelly beans, those wonderful sugar wafers?.etc,? a patient told me, describing her own elaborate scheme. ?I plotted what stores I would buy it in so they wouldn?t get suspicious and realize what I was doing."
She continued: "If the check out clerk said anything I had my rap all prepared. 'It's my kids birthday party.' I don?t even have a kid. All day I would wait till 6:00 o'clock. I'd run out of the office in a trance, like I was going to meet my lover. Trying to look casual and in control I would do my shopping, race home with my 'sacred stash' and start devouring everything. Just eating and eating in a sort of zone. Eating long after any pangs of hunger. In fact hunger had nothing to do with it. It wasn't in the equation. Despite being full I just don't stop. Then the coma would come over me and I would sort of pass out. Sometimes I'd come to and start all over again making another pit stop at the local grocery. Eventually I'd feel sick and bloated and terrible and every so guilty and bad."
At this point the bulimic either vomits or makes a pact with herself to exercise for four hours or starve for two days or whatever it takes to repent?always promising to quit the behavior just like a drug addict.
Let's face it: these situations are all bad. They all involve sick, abnormal and unhealthy behavior, which is why they are diagnosable disorders in the first place. But playing the game of obscuring the illness by creating different diagnoses is really not going to make anyone better. All eating disorder patients are suffering from conflicts that are being played out on the field of food.
From my experience with them, they are only too happy to downplay their illness by denying it. Having the ability to use a catch phrase like binge eating instead of the better-known and serious sounding diagnosis of bulimia nervosa will only encourage them to minimize their disorder. Whether the diagnosis is anorexia, bulimia, or even the as of yet unclassified binge eating disorder, call them what you will, one way or another these patients are obsessed with control and they are all focusing their attention on food and body image as a technique for avoiding the major challenges of life.
To truly treat patients with eating disorders it is far, far less important to assess the various ways they play out their disordered relationships with food, and far, far more important to focus attention on the purpose of their unhealthy behavior. Working in the clinicians? office or wherever treatment can happen, the therapist must help the client realize that their obsession with food is a distraction from the challenges of life. As long as they escape by focusing on the morsels they eat or the binges they go on, they spend less time focusing on their love life, their career, their family and their expectations. If they continue to avoid their life and keep their focus on their unhealthy relationships with food, it eventually will lead to dangerous and potentially deadly results.
We should soon start hearing news about the forthcoming update to the DSM, and if this surge in news coverage regarding binge eating is any indication, we might very well see changes in how we diagnose disordered eating. It is important though that we don?t lose sight of the real issue here, which is the health of clients. By playing the diagnosis game, and allowing them to play it, we only serve to further enable them to pass the buck and hide from the real issues in their lives that are making them sick. Diagnoses are important, but should be secondary to making sure that each patient makes progress toward a healthy life.
