Diseasing of America Continues: Binge Eating and the New DSM

The definitions of national sanity don't just change on election years. They also get revamped with each new edition of the DSM, the Diagnostic and Statistical Manual of Mental Disorders, the next (fifth) edition of which is due out in 2012.

So what, you may ask? Isn't a new and improved DSM a good thing?! It depends, of course, on how you look at it, on the level of abstraction. Let's take eating disorders, for example.

The DSM Eating Disorder Work Group is engaged in a kind of taxonomic spring-cleaning feng shui as it's trying to clear out some overflowing clutter from the so-called NOS (Not Otherwise Specified) category - which, for all intents and purposes, serves as a diagnostic waste basket. According to Stephen Wonderlich, Ph.D., 60-65% of all diagnosed eating disorders end up in the NOS bin (1).

The NOS is in essence the gray area of the diagnostic nomenclature. It's a kind of clinical terra incognita. The NOS category is a kind of bastion of clinical idiosyncrasies, a safe haven for peculiarities, oddities, and unorthodox symptom presentations.

From a clinical standpoint, the smaller the NOS territory the better since it means greater diagnostic precision and presumably more effective clinical disposition and treatment. From a cultural standpoint, once your particular mind is out of the NOS holding buffer, your mental health status becomes black and white - and you become unambiguously diagnosable! To remain "not otherwise specified" is to retain a modicum of clinical mystique and case individuality, to remain part of the nameless Dao of human experience.

In trying to empty out the NOS trash, the DSM Eating Disorder Work Group is debating whether to introduce a new eating disorder categories, a Binge-Eating Disorder (think Bulimia minus purging) (1) that for now has been lurking in the DSM appendix as a potential stand-alone entity and, when needed, diagnosed as - you guessed it - Eating Disorder NOS.

You may ask: what's the big deal? Isn't that a good thing?! The answer, once again, depends on the levels of abstraction. From the clinical standpoint, codifying binge-eating behavior into Binge-Eating Disorder makes sense: it takes the problem out of the NOS waste-basket where it's been for years. As a result, diagnosis becomes streamlined. Better diagnosis presumably leads to a more precise intervention and treatment. Furthermore, making non-bulimic binge-eating a diagnosis allows clinicians to bill for it which, in turn, allows to justify clinical services for the problem to those who need it.

On the other hand, does it really make cultural sense to take a national pastime (mindless, reactive, and, at times, emotional overeating) and turn it into a mental health disorder?! A problematic habit - yes. A living-room hand-to-mouth sport of a sedentary nation - yes. But a disorder, a disease, a mental illness?! Isn't that a bit too much?! Do we need a mental health diagnosis that will effectively make legions of otherwise undiagnosed Americans diagnostically certifiable? Do we realize how many of us - veg-in-front-of-TV stress relievers - will end up with BED (binge-eating disorder) if it becomes an official diagnosis?! Don't we already have enough diagnostic categories to pathologize a mind with?!

So, what we seem to be seeing is what Stanton Peele called diseasing of America - namely, diseasing of America's (unhealthy) habits. Just like a suboptimal habit of coping through substance use eventually progressed to the status of a medical disease, the diseasing of America's habits is now being extended to a rather basic eating behavior, a pattern of mindless, habitual, reactive eating. What's next? Are we going to also upgrade "shopaholic" behavior to Retail Impulse Control Disorder and classify participation in Second Life computer game as Virtual Reality Dissociative Disorder?

If the Binge-Eating disorder becomes a diagnostic reality, a new wave of externalizing will ripple across the national psyche. In a continued free fall of free will and personal responsibility, America is ever hungry to call a problematic habit a disease and look for a magic pill to treat it. We've come to rely on our addictions as a source of trivial heroism. After all, overcoming a habit doesn't seem as triumphant as overcoming a disease. The newly diagnosed binge-eaters will en masse join the ranks of OA (Overeaters Anonymous) or form their own BA (Binge-eaters Anonymous); and the voice of personal responsibility will once again drown in the 12-step sing-a-long anthem of surrender. What, as a nation, do we really want - powerlessness or self-control, helplessness or self-efficacy, disease or health?

Diagnosis is the beginning of prognosis. Right now, when clients seek help for overeating they tend to frame their problem as a problematic habit of mindless or emotional/reactive eating and overeating . They want skills, not pills. But once people en masse buy into the notion that their overeating is a mental illness, a disorder, they will shift to disease mentality. And the prognosis will change. After all, isn't it easier to fix a problematic habit than to cure an addiction?

The bottom line is this: our coping habits, however imperfect and suboptimal, are being made easier to pathologize. The disempowering and the diseasing of America continues. Paging Dr. Stanton Peele...

Pavel Somov, Ph.D., author of "Eating the Moment: 141 Mindful Practices to Overcome Overeating One Meal at a Time" (New Harbinger, 2008) www.eatingthemoment.com

References:
Tori DeAngelis, Revamping Our Definitions of Eating Disorders, Monitor on Psychology, April 2009, Volume 40, #4, p. 45
Stanton Peele, Diseasing of America: How We Allowed Recovery Zealots and the Treatment Industry Convince Us We Are Out of Control, Jossey-Bass, 1999