What Causes Binge Eating?

The following is not original thought and summarizes chapters from Christopher Fairburn’s Overcoming Binge Eating: The Proven Program to Learn Why You Binge and How You Can Stop. Fairburn is the creator of Enhanced Cognitive-Behavior Therapy (CBT-E), a treatment with strong research support for the treatment of binge eating disorder and bulimia nervosa.

Binge eating, like probably every mental health problem, likely stems from a constellation of psychological, social, and biological processes. No single cause is known and hence my title is somewhat misleading. A limited number of processes, however, are well-established in terms of their ability to perpetuate binge eating once a pattern has been established (in no particular order):

1. Being underweight

Individuals who are below a minimum safe weight (generally at least a BMI of 19-20) are at risk as the body attempts to fight starvation and self-preserve.

2. Being disinhibited

Substances such as alcohol, cannabis, Ambien, benzodiazepines, etc. can facilitate a loss of control over eating (including for individuals who do not have an eating disorder).

3. Strict dieting

The “restraint model of binge eating” suggests dieting is a major driver of binge eating. As evidence, binges tend to occur on or after days in which people are attempting to diet and generally involve the very foods the person is striving to avoid. Dieting is also a frequent compensatory behavior following a binge, establishing a feedback loop. Dieting can take any or all of the following forms, in this context:

· Delaying eating

· Restricting the overall amount (calorically) of food eaten

· Avoiding specific foods, typically those which feel “fattening”, “bad”, or “unhealthy”

Regardless of the real or perceived motivation for such dieting behavior, any dietary restraint or restriction which is intended to change body weight/shape should be conceptualized as “dieting”.

Everyone becomes more preoccupied with food and food-related decisions when dieting or otherwise attempting to exert control of eating. Binge eating, in part, is an understandable physiological reaction to deprivation and/or hunger.

However, more than biology is at play; black and white reactions to making and breaking dieting rules is a significant culprit. If someone has a rigid and extreme dietary rule such as “no refined carbohydrates”, eating even a small amount can trigger feelings of failure. The sense that a rule has been broken and that one’s diet has been ‘ruined for the day’ can easily cause a ricochet effect in the form of “I’ve screwed up for today, so I might as well just binge, and tomorrow I can return to never eating refined carbs again.” When rules are so rigid, failure occurs regardless of the amount by the which the rule has been exceeded. In the substance abuse treatment community, the same concept is sometimes referred to as the “abstinence violation effect”. If sobriety is lost and a total relapse has occurred after even a sip of alcohol, why not have ten beers? Recovery programs which emphasize total abstinence do create a greater buffer against relapse, but can facilitate larger and longer relapses than programs which encourage harm reduction. (Although a strictly harm reduction approach may make lapses more likely.)

I am passionate about highlighting the restraint model of binge eating. In my experience, many individuals who struggle with binge eating do not blame their strict dieting for the problem, but rather their own character. I have observed many individuals judge themselves as "gluttonous", "out of control", "greedy", and/or "a failed anorexic". All of these interpretations perpetuate the problem by renewing the commitment to strict dieting.

4. Purging

Purging perpetuates binge eating due to the mistaken belief that purging rids the body of all or most calories consumed. People who purge tend to binge more frequently and in greater quantities than those who do not. As evidence, people struggling with bulimia nervosa are significantly less likely to binge if no opportunity for purging is available. Laboratory experiments on the ‘effectiveness’ on purging are understandably limited, but suggest self-induced vomiting removes only 50% of the food consumed. Methods such as diuretic and laxative abuse have no effect on calorie absorption.

5. Emotion dysregulation

Especially in individual who engage in no dieting behavior, binge eating can also serve as an emotion regulation strategy. Binge eating tends to be experienced as powerfully calming, dissociative, and soothing – at least in the short-term.

6. Relationship problems, adverse life events and circumstances

Interpersonal Therapy (IPT), another treatment with strong research support for the treatment of BED and BN suggests that relational events such as grief, role transitions, unresolved conflict, and social isolation may lead a disturbance in self-concept and associated negative feelings which binge eating relieves.

How do CBT-E and related treatments attempt to disrupt such maintaining mechanisms? While easier said than done, the following are typical treatment targets:

1. A sense of self or source of self-esteem unduly influenced by body image concerns and/or the perceived ability to control one’s eating

2. Strict dieting, which is replaced by regular eating (a meal plan) of sufficient food quantity, in order to combat undereating/delayed/skipped eating

3. Food avoidance via the gradual reintroduction of feared/avoided/previous binge foods

4. Binge compensation via encouragement to follow the meal plan even when a binge has occurred, so as to avoid the ‘sewing the seeds’ for the next binge

5. Relationship problems, if applicable

6. Emotion dysregulation via exploring other methods of containing, tolerating, and managing uncomfortable feeling states

The next post will address to what extent binge eating should be conceptualized as an addiction. Hint - CBT-E suggests no.