Binge eating was long seen by psychiatrists as an unusual symptom of major depression or an anxiety disorder. After all, it seemed sometimes to lessen or yield to antidepressants and psychotherapy -- both aimed primarily at treating depression or anxiety.
But as anorexia and bulimia gained public recognition and as eating disorder clinics began to fill in the 1980s, the field began to see a growing group of patients who had clearly dysfunctional eating patterns yet fit the description of neither anorexia nor bulimia.
By 1994, when the American Psychiatric Assn. published the most recent edition of its diagnostic manual, binge eating was put on a watch list of conditions that might in the future be considered distinct. Since then, researchers estimate that roughly half of eating-disorder patients are identified as not fully fitting the diagnostic criteria for anorexia and bulimia. They are consigned to the diagnostic gray area called "eating disorder, not otherwise specified," or EDNOS. A large proportion of people with the diagnosis are believed to be binge eaters who do not then purge.
"We shouldn't be so conservative that we leave half the people with eating disorders with no effective labels" to help define their affliction and guide their treatment, says Columbia University psychiatrist B. Timothy Walsh, who chairs the American Psychiatric Assn.'s work group on eating disorders.
Psychologist Cynthia Bulik, a researcher and clinician at the University of North Carolina's eating disorders program, says a tight definition of binge eating disorder would do more than distinguish between the merely excessive and the ill.
It would also spur research that may find biological bases for binge eating, ultimately improving diagnosis and treatment, she says.
Similarly, recognizing it as a disorder would encourage more public and private insurers to reimburse for specialized treatment, Bulik says, which would also bring more patients into treatment.
If it gains official recognition in the APA's manual, binge eating disorder would become distinct from depression and anxiety. But that will not change the fact that binge eaters often suffer from other psychiatric disorders -- most commonly depression and anxiety, but frequently substance abuse and addiction as well. Binge eaters also cross the line to and from anorexia and bulimia at times in their lives.
According to Dr. James I. Hudson of Harvard University-affiliated McLean Hospital, 78.9% of binge eaters also struggle with depression, anxiety or substance addiction.
Meanwhile, the deliberations over binge eating disorder have forced mental health leaders to clarify their views on the relationship between excess weight and mental illness.
In a paper prepared for one of the work group's first meetings, University of Pittsburgh psychologist Marsha D. Marcus challenged members to answer a provocative question: Do all of the nation's 72 million obese adults have a mental disorder -- because, despite clear evidence of negative health consequences, they continue to consume more calories than needed to achieve a normal, healthy weight?
The group's answer, said Walsh, was a decisive no.
In the case of binge eating, he adds, mental illness can contribute to behavior that results in obesity. But not all who are obese have an eating disorder. And, in fact, not all patients who would meet the criteria for binge eating disorder are overweight. (While almost 40% of those with presumed binge eating disorder are thought to be obese, the rest are spread across the range of normal and overweight. Some, in fact, are underweight.)
Says Bulik: "We go through trends -- calling things addictions, -orexias, -aholics. People long to characterize excessive behavior somehow. . . . Sometimes, it is just excessive behavior."