A binge by any other name: Objective vs. Subjective binge eating

It’s a question I’ve been asked many times: what, exactly, is a binge anyway? Is it eating too much? Eating a lot of food? What?

The DSM isn’t necessarily much more helpful. Take the new criteria for Binge Eating Disorder (via Mayo Clinic, as the APA pulled down the draft criteria from their website) that tries to define what constitutes a binge:

  • Recurrent episodes of binge eating, including eating an abnormally large amount of food and feeling a lack of control over eating
  • Binge eating that’s associated with at least three of these factors: eating rapidly; eating until you’re uncomfortably full; eating large amounts when you’re not hungry; eating alone out of embarrassment; or feeling disgusted, depressed or guilty after eating

So what does an “abnormal” amount of food mean? What about loss of control, or rapidly? How do you define that? Some people eat faster than others, and other people might eat more or less than you. It’s why there needs to be some flexibility in the definition, but, as it stands, it’s rather nebulous. In turn, what some people might call a binge, others might call having a second helping. In the research literature, you see this discrepancy accounted for by the use of the term objective or subjective binge eating.

In his directions for administering the Eating Disorder Examination, Fairburn gives the following directions about how to define a “large amount of food”:

EDE instructions

Most of the studies I cite in this post use this definition of objective and subjective binges.

Generally speaking, the main difference between an objective binge and a subjective one is how much food is consumed. An objective binge meets the formal criteria described above: eating an abnormally large amount of food, typically in a short period of time. A subjective binge is when a person says they’ve binged, regardless of how much they’ve actually eaten. This, naturally brings up the question of how much people generally eat during a binge episode, which researchers have found most frequently lasts for two hours or less. In data compiled by Wolfe et al.the average amount eaten seems to vary fairly widely, but centers around ~2000 kcal, give or take.

 

avg BN binge

avg BED binge

 

In two different studies (Woell et al., 1989 and Rossiter & Agras, 1990), however, more than one-third of the people participating in the study said they binged when they had, in fact, consumed less than 500 calories. When it comes to defining a binge, it seems that the amount of food consumed doesn’t seem to be as large of a factor as the DSM diagnosis might have us think. To people with EDs who binge eat, a binge seems to incorporate one or more of the following:

  • is the food consumed “forbidden” by the rules of the ED?
  • does it place the person over the “acceptible” number of calories, etc, that they had allowed themselves to eat that day?
  • what is the anticipated subsequent food intake?
  • did they feel out of control while eating?
  • did the eating violate any other personal or ED-related rules?
  • was it part of a planned meal or snack?

Another reason to re-think the importance of binge size is its relationship with purging behaviors in BN.

A 2001 study by Keel et al. found that, while people with objective binge eating in BN  purged more frequently than those with subjective binge eating, they also binged more frequently. Looking more closely at the data, there was a general correspondence between the number of binges with the number of purges. This seems to indicate that if someone with BN feels they have binged, they are likely to purge. When researchers looked at adolescents with BN (thus meeting the DSM criteria of objective binge eating) and those with EDNOS who endorsed purging behaviors, they couldn’t find any major clinical differences between the two groups (Binford & LeGrange, 2005). Both groups had similar BMIs and illness duration, and both groups reported significant levels of irregular periods. There was also no significant difference in the amount or types of purging methods used. The main difference was that the EDNOS group had lower levels of body dissatisfaction, eating and weight concerns.

A separate study found that using more than one method of purging was associated with increased frequencies of both objective and subjective binges, but they didn’t compare whether these frequencies differed (Edler, Haedt, & Keel, 2007). A 2005 study by these same three researchers found that people who only subjectively binge ate had fewer weekly binge episodes than those who objectively binge ate. They also purged less frequently, but it appeared to be consistent with less binge eating. This group also appeared to show lower levels of depression, anxiety, and ED psychopathology. My review of the existing studies didn’t find any research that indicated whether people were more or less likely to purge after a subjective binge.

A more recent study compared both the ED severity and overall psychopathology in people with BN who only objectively binged, only subjectively binged, or both (Brownstone et al., 2013). None of the three groups showed any differences between types of purging or frequency of purging, level of depression, and eating, weight, and shape concerns. When the researchers compared the groups that just objectively or subjectively binged, however, the objective binge eating group was more likely to purge by vomiting and less likely to use diuretics than the subjective group. As well, the subjective binge eating group had higher levels of impulsivity. The researchers explained these finding as due to

the distorted perception of having eaten a large amount of food during SBEs (subjective binge eating episodes) would likely be related to elevated cognitive distortion among the SBE-only group. Many of the cognitive distortion items relate to a sense of dissociation from reality. This component of cognitive distortion in relation to SBE-only presentations is perplexing, and warrants further investigation into the potential relation of dissociative experience to SBE occurrence.

Thus, part of the reason that there is not much of a practical difference between objective and subjective binges is that patients can’t always tell the difference since they’re so dissociated during the binge. There also doesn’t appear to be much significance between post-binge feelings of shame and guilt. The 2005 study by Edler, Haedt, and Keel also didn’t find any difference in the rates of recovery between ED sufferers who subjectively or objectively binged, at least during the 6 month follow-up.

Rather than focusing on the size of a binge as the important factor, perhaps the better question would be to ask whether a person felt a loss of control of whether, what, and how much they were eating. That seems to be the main defining factor of a binge, rather than a size. And since the formal criteria of an “objective” binge is ultimately subjective (based on what the patient reports on a questionnaire or to a therapist, or by the therapist’s own opinion), the distinction seems rather useless.

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11 Responses to “A binge by any other name: Objective vs. Subjective binge eating”

  1. A dear lady friend of mine who struggles with binging has described knowing she is binging when she feels frantic and out of control, like she CAN’T! STOP! EATING!. Then afterwards a massive amount of shame, and the intense urge to “hide the evidence.” Another dear friend of mine who has struggled with bulimia in the past is more focused/less frantic when feeling compelled to binge- but the shame and need to hide the evidence is there after. I wonder if the shame piece for binging is significant?

    I’m not sure I understand “subjective binge.” It appears to be something the person believes they’ve done, whether they’ve actually done it or not? Does that mean someone with portion distortion who FEELS like they have binged, when in fact, others would say they have consumed a normal or less than normal amount, have, in fact binged simply because they feel that they have?

    • That’s exactly right: a subjective binge feels like a binge even though the food consumed was not an abnormally large amount.

  2. I wish that the underlying fallacy of the “binge” were addressed, well, anywhere actually.

    The underlying flaw of calling food consumption a binge when a patient is in an energy-deficit state is that we do not even accommodate their likely need for above-average consumption to rectify the energy deficit.

    Our approach to recovery for those with restrictive eating disorders is as though we are telling someone who has just stayed up for 48 hours that they need to get a good 8 hours, but OMG no more than that or that would be a sleep-binge and they’ll be out of control at that point and likely become narcoleptic and severely disabled.

    An eating disordered patient experiences consumption of food as anxiety provoking (whether or not the patient is consciously aware of that anxiety cascade or not). Any circumstance in which the patient is consuming more than he or she has identified as acceptable will be classified as “out of control” bingeing.

    Further complicating that subjectivity however is how fundamentally misguided we have been in scientifically confirming an average consumption that supports weight and health actually looks like.

    And finally, we are so fearful of fat as a society we assume that someone who has ravaged their body with years of insufficient energy intake can somehow heal and return to an optimal metabolic state while eating roughly a third less than what non-eating disordered non-dieting individuals naturally consume on average to maintain their weight and health. Women in fact consume on average 2500 calories a day (not 2000) and you’ll find the clinical doubly-labeled water confirmation of that in published research (or referenced in my blog post: I Need How Many Calories?!!).

    The entire professional community dedicated to helping those with cycles of restriction/reactive eating and sometimes purging are afraid of the same things as the eating disorder which, as Rebeckah Peebles pointed out last year, we should not be doing if we want to truly improve the rate of remission. The issue is not the “binge”, it’s the restriction.

    • Well, yes and no. When you’re looking to break the binge/purge/restrict cycle, the first step (in my mind) is to normalize eating. That means stopping the restriction after the binge eating.

      Someone who has been restricting, lost weight, and needs to regain DOES, in fact, need to consume more calories than average. That DOES NOT, however, translate into binge eating. It can be done in a controlled way.

      Your comment also doesn’t address the large majority of people who binge eat that don’t suffer from restrictive EDs. Yes, restricting food intake for short periods of time can be a part of this, and yes, this can contribute to a binge, but I wouldn’t say that have an ED that is primarily characterized by restriction. For some of these people, the binge and/or purge cycle is triggered after initial weight loss, but then it becomes ingrained and entrenched, even after the lost weight is regained. The binge eating becomes its own monster, just as restriction can.

      There are also plenty of sufferers who begin binge eating even without initial weight loss. Whether they have inadequate food intake that doesn’t result in significant weight loss is beyond me, but the point remains.

      Lastly, inadequate intake isn’t the ONLY thing that drives binge eating behavior. It’s a factor, and it can be an important one, but it doesn’t address the many emotional triggers of binge eating. If you read Tetyana’s summary of bulimia, she points out that binge eating and purging can be an attempt at emotion regulation.

      I do think that we need to understand that binge eating following restriction is common, but that doesn’t make it healthy, given the high levels of distress that follow.

  3. Unfortunately our Calvinistic belief system that emotional control should not be wielded for the consumption of food is not neurologically sound from an evolutionary perspective:

    I’ll quote myself here:

    “When you struggle with a restrictive eating disorder, so much of the social/emotional connections with food consumption have been hijacked by eating disorder-related anxieties. This disconnect is also heavily reinforced by our society’s current preoccupation with the presumed superiority of what I [now call]: the reverence [of] consciousness eating (sometimes misattributed as mindful eating).

    Consciousness eating presumes that having our emotions active and interacting with our hunger and satiation cues is inferior to the process of applying our conscious, or logical mind, to the assessment of whether the desire we feel to eat is in fact something that must be addressed for logical reasons.

    We cannot eat logically. Our logical minds are too late to the evolutionary party, by millennia, to actually offer any value to how we pursue and stay optimally energized.

    This reverence of the logical mind and twinned disdain of the emotional mind is, from an evolutionary perspective, ludicrous. The structures within your brain that support your emotional landscape are robust, distributed and ensure your survival to a level that your logical mind couldn’t even hope to achieve on its best coffee-upped day!

    I often mention the patients with lesions and trauma to the emotional centers of the brain (you’ll find one in particular who is referenced by multiple neuroscientists and neurologists in their bestseller books) who are institutionalized despite the fact that they have fabulous and intact IQs; have completely intact memory, retention and retrieval faculties; and can sustain a conversation on any topic pertaining to the past (historical and personal) to the present and future (current affairs, debate, analyses etc.). Ask them what they would like to have for lunch and then you see why they need the 24/7 oversight and care. Without emotional salience, their logical mind is completely stymied by what might be the better option: lasagna or burger and fries.

    How you feel about your food is how you not only survive, but also thrive.”

    Re-feeding in “a controlled way” is likely another facet of the same pathology that causes food to continue to be identified as a threat.

    Yes I’ve read Tetyana’s blog post and her observations align with my understanding of restrictive eating disorders. A restrictive eating disorder is a deadly dance of anxiety modulation (or emotional regulation). Emotional factors may indeed trigger a binge, but are those emotional factors wrong? Perhaps not. Perhaps they are more capable of identifying energy deficiency on a systemic level (despite weight restoration)?

    When a woman sits down with a tub of ice cream after her boyfriend breaks up with her, is she bingeing? Let’s say she is for argument’s sake. Is that bad? Well she doesn’t logically need the energy I’m sure everyone would agree — she’s just sitting on the couch moping, right?

    The majority of menstruating women “binge”, primarily on carbohydrate/fat rich foods, at least once a month and usually in the luteal phase. This monthly binge does not impact optimal weight (they stay weight stable). It is thought that this behaviour may modulate serotonin during this phase of cycle. References on my site for all this burble BTW.

    What if the meme of a tub of ice cream to soothe a broken heart allows for real neurotransmitter modulation that actually results in feeling soothed? The brain is 4% of our body by weight and demands 20% of the energy we take in — it is pathetically simplistic to relegate energy management in our bodies to the first law of thermodynamics while failing to incorporate the second law of thermodynamics. Quality of energy is not maintained, and how and where energy is degraded is the miracle of our body’s ability to maintain its optimal weight set point without our paltry logical interference.

    If a brain affected by a restrictive eating disorder is understood to have, in some way, misidentified food as a threat, then the individual faces a torturous problem: not eating is not viable long term, but eating generates heightened anxiety (anxiety being the result of a threat response that is meant to trigger avoidance of the threat). Anxiety that triggers avoidance from a rustle in the bushes is a good survival technique, but when threats are misidentified, then avoidance becomes pathology.

    Cycles of restriction/reactive eating and purging are the elaborate anxiety modulation techniques that tend to originate from an initial effort of restriction. 62% of all patients who begin with restriction end up with bulimia within 8 years of the onset of a restrictive eating disorder precisely because depletion of the body’s energy reserves pushes the patient to have to eat, thereby worsening anxiety and the development of compensatory responses such as purging. As Tetyana pointed out, she often felt tremendously calm and at ease after purging — and that is to be expected — it is reinforcing a maladaptive threat avoidance response.

    I think it is unwise to assume that because “bingeing” is distressful to someone with a restrictive eating disorder that it is therefore unhealthy. What is objectively unhealthy is having food identified as a threat in one’s mind because it will involve a constant level of vigilance towards food consumption that will result in energy deficits even if they predominantly go unnoticed by both patient and professional alike.

    When a schizophrenic becomes highly distressed because he is forced to enter a room with a computer, we may indeed remove the computer to help him, but we don’t make the leap of assuming that the computer is therefore “unhealthy” for him to experience or be near.

    The only difference is that all of society is happy to accept the unsubstantiated belief that “bingeing is bad” whereas we can instantly identify that the schizophrenic has misidentified the computer as a threat without batting an eye. And no, I do not hold that schizophrenia has much in common with restrictive eating disorders and I use the condition only as a parallel example.

    I am actually coming to the conclusion that we may have to argue that restrictive eating disorders are actually normative in our society, as is women’s overall dissatisfaction with their bodies, because we cannot identify treating food as anything other than a threat on a society-wide scale in our culture today.

    And that would mean my entire diatribe here must mean I have more in common with a schizophrenic who has lost touch with consensus-based reality precisely because I am someone without an eating disorder who can happily binge as moods might dictate. And that nullifies my views brilliantly — too bad I cannot be more succinct about it eh? :-)

    Finally, sincere apologies for the huge response and grateful appreciation for inclusion in this discussion on your blog!

    I won’t tackle the bingeing in the absence of restrictive eating — I’d outstay my welcome here for sure (I cover it off in my blog post on BED and NES).

  4. It’s one of the things I’ve really struggled with as I’ve tried to stop restricting. Eating “normally” feels like bingeing; slipping from a sensible amount of food into a binge is so easy because I feel like I’ve already started the binge, so why not just keep going. And then trying to justify that it isn’t a “real” binge, because the calories aren’t high enough, or because I spread it out over an afternoon. This post is a recognition that EDs are more complex than just fitting pre-set criteria. All those other things (shame, guilt) are there when I eat anyway, so what’s the difference between a meal and a binge??

  5. Yes, agreeing w/C here- what is the difference between a meal and a binge? I still feel confused.

    I just started to recognize my body’s hunger cues in the past few years- my stomach doesn’t give me cues- but I might get shaky or dizzy or start to dissociate and that can be a cue. One time a few months back I was struggling with restricting and I got really shaky and loopy in the head and I recognized that as a cue- so I took a bag of trail mix- and instead of measuring it out to just eat one serving, I closed my eyes and just ate handfuls until I stopped shaking. It was effective in stopping the shaking- but I felt painfully ashamed and upset after. It was not the whole package but I had not measured it and I felt like a pig. I regretted it severely.

    I thought it was a binge. When I reported it to my dietitian, she said it was not. She said it was “normal.”

    But it felt like a binge. So was it a binge?

    • Yes, I remember this from my early recovery times–any eating felt like such a failure, that I thought I had binged any time I ate without my usual rules. But when I look back on my journal entries from that time, I think “um, four pieces of bread and a banana? that cannot be a binge.” Except if I understand you all correctly, subjectively it could? Weird.

  6. This is an interesting article. Sometimes we find that patients (specifically athletes who have a high caloric expenditure) tend to eat large volumes of food during the latter part of the day and consider it a binge when it is just them “making up” for calories not consumed during earlier parts of the day.

  7. I think this is a really interesting post and so are the replies. Having suffered from anorexia for 5 years, I experienced a period of binge-eating last year which went on for about two months. During that time I would have both “subjective” and “objective” binges interspersed with restriction phases. Overall my weight stayed stable, so I expect that most of the “binge” episodes were really just by body screaming out for food given my undernourished state long term and cycles of restriction. However, although it may be the case that I needed this food and therefore yes Gwyneth I did have a need for it and it may be a mistake to label this behaviour as wrong given I was following by body’s biological demands, as Carrie points out there were ways I could have met my energy requirements without binge eating which would have been a) more “normal” and b) a hell of a lot more manageable. Although there may be nothing really wrong with bingeing, it left me feeling distraught with an aching stomach for days and highly highly anxious despite the short term soothing power it had. It may be true that the binge eating did allow for certain neuro-transmitters to be produced/released but the point is that there are other ways that this can be achieved (through social contact, hugs, exercise etc.). I guess my point is that while binge eating can be explained as a biological drive to meet energy requirements and may soothe because it allows for hormone production/secretion, there are other methods to achieve both of these aims. Routinely eating above current calorific need will fulfil the energy deficit and seeking social support, having rewarding hobbies, caring for yourself can replace the soothing function of binge eating.

    Having said all of this I still struggle with even defining a binge. I went out for dinner last night, had a main course and a large slice of cake with custard and am now looking back on it thinking it was a binge even when I a) enjoyed it b) didn’t rush and was consciously aware of what I was doing c) it was no more than either of my friends ate d) had been feeling under-fed for a few days beforehand. This is when I think we have to be careful labelling it as a “subjective binge”. Although this captures how I feel I don’t think it helps to encourage normal eating patterns. When every other person would call it “a nice normal meal out with friends” it seems that a more productive approach would be to recognise there are objective binges where people eat significantly more than is normal FOR THEM AND PEOPLE LIKE THEM (i.e. a binge for a 5ft 2 light eater is not the same as a binge for a 6ft 5 marathon athlete due to their differential base energy requirements), but that anything which could be included within a typical eating profile should be seen as “normal”. most definitions of normal eating include some phrase referring to it being normal to eat more than is comfortable or more than you might on reflection sometimes.

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