http://informahealthcare.com/jmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, Early Online: 1–6 ! 2015 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2015.1019049
ORIGINAL ARTICLE
Binge eating as a meaningful experience in bulimia nervosa and anorexia nervosa: a qualitative analysis Karin Eli
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Institute of Social and Cultural Anthropology, University of Oxford, Oxford, UK
Abstract
Keywords
Background: Clinical studies describe binge eating as a reaction to hunger, negative affect, or the need to dissociate. However, little is known about the meanings that women with bulimia nervosa and anorexia nervosa associate with binge eating. Aims: To examine how women with anorexia nervosa and bulimia nervosa interpret their experiences of binge eating. Methods: Sixteen women who engaged in binge eating and had been diagnosed with anorexia nervosa, bulimia nervosa, or their subclinical variants were interviewed about their experiences of eating disorder. Interview data were analyzed using phenomenologically-informed thematic analysis. Results: Participants described binge eating as a practice through which the self experiences a sense of release, and existential emptiness is replaced by overwhelming fullness. Conclusion: Meaningful experiences of release and fullness are central to binge eating in bulimia nervosa and anorexia nervosa, and may contribute to the long-term maintenance of this practice.
Anorexia nervosa, bulimia nervosa, eating disorders, lived experience, qualitative analysis
Introduction Binge eating is a defining feature of bulimia nervosa, and is a common feature of anorexia nervosa (APA, 2013). Several clinical studies have analyzed binge eating as a response to hunger, negative affect (stress, anxiety, and low self-esteem), or a need to dissociate (Engelberg et al., 2007; FullerTyszkiewicz & Mussap, 2008; Heatherton & Baumiester, 1991; Steinberg et al., 1990; Swirsky & Mitchell, 1996; Waters et al., 2001). Other studies have positioned binge eating within a larger cycle of emotional mediation, wherein the binge episode is preceded by negative mood, and the eventual purge functions as emotional ‘‘regulator’’ (Alpers & Tuschen-Caffier, 2001; Cooper et al., 1988; Lynch et al., 2000; Powell & Thelen, 1996). While these studies offer differing hypotheses on binge eating, all suggest that binge eating is emotionally, physiologically, or socially ‘‘functional’’ (Davis & Jamieson, 2005; Jeppson et al., 2003), facilitating a temporary transition from negative to positive states. While eating disordered practices are functional, they are also existentially meaningful. Medical anthropologists have examined embodied meanings of self-starvation in anorexia nervosa, highlighting how values such as asceticism and purity shape anorexic people’s lived experiences (O’Connor & Van Esterik, 2008; Warin, 2009). Binge eating, however, Correspondence: Karin Eli, Institute of Social and Cultural Anthropology, University of Oxford, 51-53 Banbury Road, Oxford OX2 6PE, UK. E-mail: [email protected]
History Received 12 August 2014 Revised 17 December 2014 Accepted 21 December 2014 Published online 18 May 2015
has not been similarly investigated. Interview-based analyses have focused on participants’ contrasting of bulimia nervosa and anorexia nervosa (Burns, 2004), discussions of bulimic practices as self-victimizing, abject, and shameful (Brooks et al., 1998; Broussard, 2005), or use of binging and purging as a means to physiological, emotional, and social ‘‘wellbeing’’ (Jeppson et al., 2003). Still, little is known about the meanings that women with bulimia nervosa and anorexia nervosa ascribe to binge eating. In light of recent work suggesting that misconceptions about eating disorders hinder effective treatment seeking and referral (Mond, 2014; Ra¨isa¨nen & Hunt, 2014), and that gaps between clinical concepts and patient experiences may form a barrier in mental health care (Black et al., 2014), this study aims to elucidate how patients interpret their binge eating experiences.
Methods This study analyzes accounts of binge eating narrated by 16 women (18–38 years old at first interview) who had anorexia nervosa (with bingeing and purging symptoms), bulimia nervosa, or their subclinical variants (eating disorder not otherwise specified [APA, 2000]). The 16 participants were interviewed as part of a larger, longitudinal medical anthropology study (n ¼ 36) concerning the subjective experience of eating disorders in Israel (2005–2006 and 2011). The larger study also included participants who had restrictive anorexia nervosa and participants who practiced purging only (without antecedent binge eating); these participants were excluded
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from the present study. The analysis relies on the interviews conducted in 2005–2006, as the 2011 interviews focused on processes of chronicity and recovery, and elicited participants’ reflections on experiences they described in the study’s first phase.
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Study setting Israel has been of interest to eating disorders researchers due to its ethnic and religious composition, sizable populations of recent immigrants, and ongoing armed conflicts. These attributes, as some researchers have argued, set Israel apart from its European and North American counterparts, making it a testing ground for the impact of Westernization on the development of eating disorders (see Latzer et al., 2008). Indeed, Israeli public health studies concerning disordered eating have emphasized comparisons across ethnic, religious, and native-born/immigrant sub-populations, with the aim of determining which groups are at greater risk for eating disorders (Latzer et al., 2008). Going beyond the Westernization concept, medical anthropologists have argued that eating disorders in Israel are influenced by locally specific experiences and values, including compulsory military service (Eli, 2014) and the framing of motherhood as a path to women’s ‘‘good’’ citizenship (Gooldin, 2002). As Gooldin (2002) argues, eating disorders in Israel may be ‘‘glocal’’, interweaving Western and Israeli values. Estimates of the prevalence of eating disorders in Israel rely on informal observations by local experts, who cite rates similar to those found in Western Europe and North America (Rabinovitch, 2011). Epidemiological research on eating disorders in Israel is scant, with only a few early studies conducted among limited populations (e.g. military recruits [Scheinberg et al., 1992]). To date, no comprehensive population-based study concerning the prevalence of eating disorders in Israel has been published. Studies utilizing
eating attitudes questionnaires (such as EAT-26) among nonclinical samples suggest that disordered eating attitudes and practices are prevalent among young Israeli women (Latzer et al., 2008). Most major eating disorders treatment centers in Israel are government-subsidized, and managed by the Ministry of Health or Israel’s Kupot Holim (non-profit healthcare funds); private treatment options, however, are also available. While some of this study’s participants sought private treatment for eating disorders, most received treatment in Kupot Holim or Ministry of Health outpatient clinics and inpatient wards. Participants The sample of 16 included six women who had bulimia nervosa, four women who had anorexia nervosa (including one with past bulimia nervosa), three women who said they had anorexia nervosa and bulimia nervosa simultaneously, two women who identified as having a non-specific eating disorder, and one woman who had concurrent, conflicting diagnoses of bulimia nervosa and anorexia nervosa. All women received treatment for their eating disorders, and were diagnosed by clinicians: nine were treated in outpatient settings only, and seven were treated in inpatient and outpatient settings; 12 participants were receiving treatment at the time of first interview. The participants’ duration of eating disorder ranged from 1 year to 23 years; their duration of binge eating practices ranged from under 1 year to approximately 16 years (Table 1). All participants were Israeli and Jewish. At the time of first interview, nine participants had a university degree or pursued university studies, six participants had completed secondary education, and one participant had less than 10 years of education. Eleven participants completed their compulsory military service; the remaining five were exempt due to their mental health status and other reasons.
Table 1. Summary of participant eating disorder characteristics.
Participant ID
Gender
Age at first interview
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Female Female Female Female Female Female Female Female Female Female Female Female Female Female Female Female
21 25 38 31 18 20 26 20 23 38 25 37 31 21 22 26
a
Eating disorder diagnoses (in adulthood)a
Estimated age at eating disorder symptom onsetb
Estimated duration of binge eating practices (in years)c
In treatment at the time of first interview
BN EDNOS BN AN and BN AN AN EDNOS AN and BN BN (past AN) AN (sub-clinical; past BN) BN AN and BN BN AN and BN AN BN
16 16 12 19 17 19 20 12 15 15 17 17 14 15 18 16
5 9 16 8 51 51 3 51 7 6 8 10 16 6 4 8
Yes Yes No No Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes
Diagnoses were self-reported by the participants. Estimated age of onset was self-reported by the participants. In some cases, the participants’ self-reported age of onset preceded their age at clinical diagnosis by several years. Some participants described dietary restriction as their main eating disorder symptom at onset, with binge eating appearing months or years later. c Estimated duration of binge eating practices is based on the participants’ narratives of their eating disorder histories. b
Binge eating as a meaningful experience
DOI: 10.3109/09638237.2015.1019049
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Recruitment Participants were recruited through an outpatient eating disorders clinic (n ¼ 7), an online pro-recovery eating disorders discussion board (n ¼ 6), and an informal chainreferral network (n ¼ 3). The participants recruited through chain-referral were initially contacted by the study’s key participant; those who were recruited through the clinic were initially contacted by a member of the clinical team. After they had indicated interest in the study to their ‘‘mediator’’, and had agreed to share contact details, the author contacted the potential participants by telephone, explaining the study, answering any questions they had about participation, and then asking if they might wish to participate. To recruit participants through the eating disorders discussion board, the author posted three messages with information about the study, and invited readers who wanted additional information to contact her through the discussion board’s messaging system. The author communicated with those who expressed interest in participating through message exchanges and telephone conversations, following a process similar to the one described above. Ethics The first phase of the study was approved by the author’s university’s ethics committee (June 2005), and was also approved by an Israeli Kupat Holim Helsinki Ethics Committee (August 2005). The second phase of the study was approved by the author’s university’s ethics committee (February 2011) and did not require Helsinki ethics approval. The participants provided written consent for this study. All names used in this article are pseudonyms, and identifying details have been concealed or altered to ensure confidentiality. Data collection The study relied on in-person semi-structured interviews. The interviews took place in locations the participants selected, usually their homes, parks, or cafes. The author, a medical anthropologist, opened the majority of interviews by asking, ‘‘when and how did it begin?’’ – a question that framed the participants’ illness narratives. While the author explored the participants’ experiences of eating disorder through similar follow-up questions, aimed at addressing several key topics (e.g. body image, perceptions of food), the selection of follow-up questions, question order, and phrasing varied according to each participant’s narrative. This approach enabled the emergence of participant-led accounts, reflecting their varied histories, modes of expression, and experiential foci. The author respected the participants’ narrative choices, and only questioned them about experiences of binge eating after they had mentioned this practice. Data analysis The interviews were digitally recorded and transcribed, and supplemented with written notes. As the study was designed to focus on participants’ experiences and interpretations thereof, data were analyzed using phenomenologically-informed thematic analysis (Braune & Clarke, 2006). A phenomenological
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orientation was chosen to emphasize the participants’ subjective experiences and the meanings they assigned to them; the thematic analysis approach enabled the identification of patterns of experience and meaning across the sample. The author extracted and collated the interview sections that concerned binge eating, and carried out an initial coding of the extracts for participants’ experiences and interpretations of binge eating. She used the emergent codes to guide a de-novo analysis of the entire corpus for overarching subthemes, and then used a spreadsheet to record which subthemes occurred in each interview, ensuring their accurate representation in the analysis. Subthemes that expressed similar experiential patterns (e.g. binge eating associated with a sense of compensation, release, or excitement) were brought together to develop the two larger themes this article explores. The author defined and named these themes according to the central meaning participants associated with the experiences they captured (e.g. compensation, release, and excitement could all be defined under ‘‘binge eating as embodied release’’). All quotes used in this article were translated by the author from the original Hebrew. During the translation process, the author noted Hebrew phrasings that could not be translated directly (e.g. ‘‘going up’’ for gaining weight). The participants’ descriptions of binge eating experiences had direct counterparts in English.
Results Binge eating as embodied release Binge eating practices were related to the sensation of hunger itself, and to the experience of practicing dietary restriction, both past and present. Participants described binge eating as effecting embodied release from restrictive practices, using the words ‘‘liberating’’, ‘‘compensatory’’, and ‘‘exciting’’. Some participants described binge eating as an immediate, uncontrollable response to prolonged hunger. For example, Aline, who began to practice binge eating after months of restricting anorexia, said: ‘‘I had those breaking points when I would just devour everything I see around the house’’. Others, like Orit, described binge eating as a planned climax following a period of self-starvation: ‘‘succeeding [in carrying out a binge] was definitely exciting’’. However, the hunger to which the participants referred extended beyond the immediacy of present-day associations, and encompassed memories of past starvation. Hadas, who began to practice binge eating after she was hospitalized for anorexia nervosa, spoke of binge eating as a liberating experience. Seven years after recovering from anorexia nervosa, Hadas was undergoing a recovery process for bulimia nervosa, and continued to struggle with her binge eating practices: I’m still trying to satiate the hunger I created in myself then. (. . .) It’s not like during the entire [anorexic period] I didn’t want to eat – I wanted to eat, but I was in the prison, like, I couldn’t eat even when I wanted to, even when I was, like, dying of hunger, I couldn’t allow myself to eat. (. . .) [T]his release is so much fun, the food, suddenly you discover what a pleasure it is, how much it’s, how much you’ve missed it, you just can’t stop.
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Hadas interpreted the emergence of her binge eating practice as driven by both physical and emotional restriction, wanting nourishment and ‘‘pleasure’’, and thus conveying her need for food for both survival and life. The sense of release associated with binge eating, however, was linked not only to the sensation of hunger, but also to the sense of being controlled, even subjugated, by restrictive dietary practices. While participants associated restrictive practices with feelings of willpower and control, restriction also emerged as compulsive, punishing, and oppressive. Mirah, who engaged in binge eating and purging for over 15 years, used the metaphor of a ‘‘well-oiled German machine’’ to describe herself during bouts of starvation. Ma’ayan, who engaged in binge eating for about 3 years, said she felt there was a ‘‘monster [that] sat inside [her] head’’, inflicting a Nazi-like starvation regime ‘‘like they did to the Jews in the concentration camps’’. Both women alternated days of starving with days of binge eating. Although Mirah said she often felt humiliated by her binge eating, she also described bingeing as ‘‘a sensation of freedom and excitement’’, saying: ‘‘it was actually who I was (. . .) the binges, it was the most authentic thing I had in life’’. For Ma’ayan, binge eating was a way of allowing herself, following bouts of starvation, ‘‘to taste, like, all the things there are in the world, before she [the monster] decides I’m not eating anymore’’. Through using highly loaded imagery related to the Holocaust, both Mirah and Ma’ayan conveyed a sense of being incarcerated, coerced, and even dehumanized by their own restrictive practice. ‘‘Filling up’’ an existential emptiness Binge episodes often began with sensations the participants described as ‘‘abnormal’’ hunger, overwhelming cravings, or a frightening/disquieting emptiness. Participants described their binge episodes as directed at the sensation of intense, overwhelming fullness. Some described rummaging through the entirety of their kitchens, consuming combinations of food they considered otherwise inedible, and bingeing unto exhaustion to achieve the fullness they sought. Tamar, who engaged in binge eating and purging for more than 15 years, said she continuously shopped for food during binges to maximize fullness: I had to reach a condition where my stomach already really ached, it was already – I couldn’t put [food] in, but I put more and more and more in. (. . .) I sat stretched, with nausea already, it was clear that there’s already no space for anything, but I’ll eat another packet of biscuits and then, like, reach the edge. For Tamar, as for other participants, the sensation of pain induced by binge eating was both the signal and the embodiment of sought-after fullness. The need for ‘filling up’ was in continuous dialogue with the sensation of emptiness. Galit, who engaged in bingeing and purging practices for about a decade, said that, during a binge ‘‘[you eat] until you feel that you’re being torn, that you can’t move anymore’’, an experience she interpreted as ‘‘responding to some emptiness’’ and ‘‘existential problems’’.
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Angie, who engaged in bingeing and purging for 6 years, explained that her binge eating used to occur only when she felt deep emotional pain; over time, however, it became part of her ‘‘routine’’, a method to cope with ‘‘quietness’’. This ‘‘quietness’’ was so unbearable that she practiced cycles of bingeing and purging, sometimes repeatedly, despite suffering from hypokalemia and other life-threatening complications: Many times it happens to me that then, very quickly I, like, feel the emptiness again, and then I have to fill up again. Like, sometimes it really, like, for hours upon hours upon hours, like, eating, vomiting, eating, vomiting, eating, vomiting. Until I’m exhausted already and I go to sleep. The need for a binge, she said, was ‘‘stronger than [her]’’; the emptiness would drive her out of bed at night, through bouts of severe insomnia, leading to a disturbing sense that she had no ‘‘other things in life’’ but food. The underlying emptiness, as the participants described it, was an ambiguous, ongoing, and unsettling sensation. Adi, who engaged in bingeing and purging for about 8 years, said that bulimia was her ‘‘anchor’’, and that she used to carry food in her bag to feel security and warmth: ‘‘The emptiness always frightened me. The emptiness meant beginning to cope with things as they are’’. Adi said she dreaded the sensation of hunger, the rumbling of an empty stomach; she was afraid of not having food at her disposal and not being able to soothe the emptiness inside. The emptiness she feared, however, extended beyond hunger: That same void in the stomach, as far as I’m concerned, is allegorical to that same void that you feel in the soul. (. . .) I really didn’t find anything that’s so close to a sensation of satiety, to a satiety from life, because I never reached this satiety from life itself, from the doing itself, from what I’m achieving in life. And from food – yes. Food – I ate, I was satiated, I vomited. Adi later said her binge eating was an act of ‘‘devouring the entire world’’. Her many professional aspirations had all dissipated, and as one disappointment followed another, she felt increasingly dissatisfied. Food, however, being simple and material, could offer an immediate (if temporary) alleviation of gnawing emptiness. As succinctly described by another participant, Shiri, who spoke longingly of binge eating after 8 years of eating disorder, food provided the ultimate – and perhaps the only – means to contend with emptiness: ‘‘It’s something that, nothing else ever filled me up like that, like the food did, [and] I don’t think anything [else] ever will’’.
Discussion The experiential meanings of binge eating, as the participants described them, were grounded in embodied sensations. While binge eating emerged in response to dietary restriction, it was not merely a hunger for food that this practice addressed. Rather, as the participants described it, binge eating was related to sensations of release or fullness (with some participants evoking both). These themes were consistent with findings described by Jeppson et al. (2003), who
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DOI: 10.3109/09638237.2015.1019049
reported on participants for whom binge eating was a physiological, sometimes euphoric, ‘‘release’’ from dietary inhibitions (p. 123), and quoted one participant who said binge eating filled the ‘‘emptiness’’ of feeling ‘‘hungry for love’’ (p. 121). In the present study, the sensations of release and fullness were sought-after responses to experiences of restriction and emptiness. Notably, release and fullness had both felt and cognized dimensions: while these sensations were intensely embodied through the process of ingesting food and accompanied by experiences such as excitement or pain, they were also metaphors for existential states. The release participants felt through binge eating was an active, bodily response to the ongoing experience of being restricted, or ‘‘imprisoned’’. Likewise, the fullness achieved through a binge was an overwhelmingly felt response to states of emotional emptiness. These findings suggest that experiences of binge eating constitute a metaphoric, embodied expression and negotiation of existential states. In the participants’ accounts, emotion and bodily sensation were inseparable; food and eating practices thus provided a literal expression of states of being, such that, for example, the sense of existential emptiness could be literalized and (temporarily) negated by the ‘‘filling up’’ process of a binge. The use of metaphors among women with anorexia nervosa has been noted by Ska˚rderud (2007, p. 168), who calls attention to the sensation of emptiness, drawing links ‘‘between the physical act of emptying the stomach and bowels, and clarifying one’s mind’’. Women with anorexia nervosa, argues Ska˚rderud (2007, p. 163), equate the physical and the emotional through bodily ‘‘concretized metaphors’’, revealing a compromised ‘‘symbolic capacity’’. However, eating disordered practices are not mere reflections of pathology: they implicate socially salient values and courses of action. In her analysis of anorexic being-in-theworld, Warin (2009) argues that anorexic practices of restriction and purging are rooted in culturally meaningful anxieties about avoiding abjection, preventing contagion, and maintaining cleanliness. Viewed through this lens, the practices this study’s participants described were embedded in normative discourses of empty and full lives, and in associations of starvation with the Holocaust and imprisonment. For the participants, the metaphoric linking of existential and binge-related experiences was visceral, articulated first, and primarily, through the immediacy of bodily sensations. Kirmayer (1992, p. 339) argues that the ‘‘bodily grounding of metaphor’’ is central to the experience of illness. Through bringing together culturally recognized meanings, the ailing body, and individual perceptions, metaphoric expressions situate expressions of illness within frameworks of sense-making (Kirmayer, 1992). As other anthropologists have argued, emotional expression itself links the sensory and the symbolic (Boellstorff & Lindquist, 2004). Emotion, argues Lyon (1995), is profoundly felt; grounded in the body, it implicates both individual sensory experiences and the social environments that inform them, such that mental, bodily, and social dimensions cannot be separated. As an example, Lyon (1995) cites Lakoff’s (1987) contention that metaphorical and physiological expressions of anger are
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interlinked – ‘‘being hot with anger’’ is, quite literally, embodied. The feeling body, then, lives and communicates experience through culturally meaningful idioms. ‘‘To be anxious’’, writes Leavitt (1996, p. 515), ‘‘is to have a feeling associated with meaning’’. In the participants’ accounts, the bodily and the existential could not be disentangled: physical emptiness not only symbolized existential emptiness, but also constituted its very embodiment. As the participants experienced and articulated persistent distress through concepts related to food and eating, their binge eating practices held felt meanings that could contribute to the long-term maintenance of their eating disorders. Clinical implications The findings suggest that existing clinical models of bulimia nervosa and anorexia nervosa can be strengthened by including the experience of binge eating as a potential disorder maintaining factor. In the most influential model of bulimia nervosa – Fairburn et al.’s (2003) cognitive-behavioral theory – binge eating is conceptualized as a response to deviations from dietary restriction: the model frames dietary restriction as driving the disorder, with binge eating maintained through its mediating effects on mood and reinforcement of psychopathology. Although cognitive-behavioral therapy (CBT-BN) is the most effective treatment for bulimia nervosa, it is only moderately successful; as Fairburn et al. (2003, p. 515) note, this may reflect the model’s incomplete accounting for disorder ‘‘maintaining mechanisms’’. Fairburn et al. (2003) offer an enhanced model (CBT-E) that includes maintaining mechanisms such as ‘‘clinical perfectionism’’ and ‘‘mood intolerance’’ (p. 509), alongside the core ‘‘overevaluation of eating, body shape and weight’’ (p. 510; see also Murphy et al., 2010). However, while this model accounts for the mood regulation effects of binge eating, it does not address patients’ valuation of binge eating experiences. This study’s findings demonstrate that, in their descriptions of binge eating as ‘‘release’’ and ‘‘fullness’’, participants defined binge eating not as the corollary of a more meaningful dietary restriction, but as a valued practice unto itself. Indeed, while they endorsed ideals of dietary restriction and thinness, many participants described binge eating as their disorder’s core practice. This suggests that treatment models should include the experience of binge eating as a possible maintaining mechanism. Such conceptualizing of binge eating as a driver of disorder would potentially allow clinicians to devise treatment for patients whose disorder mechanisms are not captured in the extant, dietary restrictionfocused models. Limitations All participants were women, and all but one had completed secondary education, such that the representativeness of the sample is limited. Further research is needed to determine whether men, children, and women of lower educational attainment who engage in binge eating ascribe similar meanings to their practices. Additionally, as this study’s participants engaged in compensatory practices, future studies should explore the meanings that people diagnosed with binge
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eating disorder ascribe to binge eating. Of the larger study sample (n ¼ 36), a few participants chose not to discuss binge eating despite having engaged in this practice. The analysis may be limited, therefore, to participants who were ready to speak about binge eating experiences with a researcher, although it is possible that participants did not discuss binge eating because they perceived this practice as less salient to them at the time of interview. Moreover, as participants selfreported their diagnoses, discrepancies between assigned and reported diagnoses are possible. It should also be noted that data collection and analysis were conducted by a lone researcher; while this is common practice in anthropology, it precluded obtaining inter-coder reliability. Finally, although data were translated carefully, some linguistic nuances cannot be translated directly from Hebrew to English.
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Conclusion While undeniably functional, binge eating has important existential meanings for people with bulimia nervosa and anorexia nervosa, and should not be conceptualized as a mere means to an end. As this study showed, participants articulated ongoing states of adverse feeling through metaphoric meanings related to food and eating, with words such as ‘‘emptiness’’ and ‘‘imprisonment’’ used to express distress. Such meanings provided fertile ground for habitual engagement in binge eating, which was conceptualized and experienced as ‘‘filling up’’ and ‘‘releasing’’. Addressing meanings of binge eating and their antecedent feelings in treatment could prove useful, particularly where long-term binge eating practices are concerned.
Declaration of interest The author has no conflicts of interest to report. The second phase of the study was supported by a grant from the Oxford University Press John Fell Research Fund.
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Davis R, Jamieson J. (2005). Assessing the functional nature of binge eating in the eating disorders. Eat Behav, 6, 345–54. Eli K. (2014). Eating disorders during compulsory service in the Israeli Defense Forces. Mil Behav Health, 2, 89–97. Engelberg MJ, Steiger H, Gauvin L, Wonderlich SA. (2007). Binge antecedents in bulimic syndromes: An examination of dissociation and negative affect. Int J Eat Disord, 40, 531–6. Fairburn CG, Cooper Z, Shafran R. (2003). Cognitive behaviour therapy for eating disorders: A ‘‘transdiagnostic’’ theory and treatment. Behav Res Ther, 41, 509–28. Fuller-Tyszkiewicz M, Mussap AJ. (2008). The relationship between dissociation and binge eating. J Trauma Dissoc, 9, 445–62. Gooldin S. (2002). Anorexia in Israel or ‘‘Israeli Anorexia’’? Some remarks on a culture-bound syndrome in a global context. Israeli Sociol, 4, 105–42. Heatherton TF, Baumeister RF. (1991). Binge eating as escape from selfawareness. Psychol Bull, 110, 86–108. Jeppson JE, Richards PS, Hardman RK, Granley HM. (2003). Binge and purge processes in bulimia nervosa: A qualitative investigation. Eat Disord, 11, 115–28. Kirmayer LJ. (1992). The body’s insistence on meaning: Metaphor as presentation and representation in illness experience. Med Anthropol Q, 6, 323–46. Lakoff G. (1987). Women, fire and dangerous things: What categories reveal about the mind. Chicago (IL): University of Chicago Press. Latzer Y, Witztum E, Stein D. (2008). Eating disorders and disordered eating in Israel: An updated review. Eur Eat Disord Rev, 16, 361–74. Leavitt J. (1996). Meaning and feeling in the anthropology of emotions. Am Ethnol, 23, 514–39. Lynch WC, Everingham A, Dubitzky J, et al. (2000). Does binge eating play a role in the self-regulation of moods? Integr Physiol Behav Sci, 35, 298–313. Lyon ML. (1995). Missing emotion: The limitations of cultural constructionism in the study of emotion. Cult Anthropol, 10, 244–63. Mond JM. (2014). Eating disorders ‘‘mental health literacy’’: An introduction. J Ment Health, 23, 51–4. Murphy R, Straebler S, Cooper Z, Fairburn CG. (2010). Cognitive behavioral therapy for eating disorders. Psychiatr Clin North Am, 33, 611–27. O’Connor RA, Van Esterik P. (2008). De-medicalizing anorexia: A new cultural brokering. Anthropol Today, 24, 6–9. Powell AL, Thelen MH. (1996). Emotions and cognitions associated with binging and weight control behavior in bulimia. J Psychosom Res, 40, 317–28. Rabinovitch M. (2011). Frameworks for eating disorders treatment. Submitted to the Committee for the Advancement of Women’s Status; 2011 Jul 25; The Knesset Centre for Research and Information. Available from: www.news1.co.il/uploadFiles/968349635601044.doc [last accessed 16 Dec 2014]. Ra¨isa¨nen U, Hunt K. (2014). The role of gendered constructions of eating disorders in delayed help-seeking in men: A qualitative interview study. BMJ Open, 4, e004342. Scheinberg Z, Bleich A, Koslovsky M, et al. (1992). Prevalence of eating disorders among female Israeli Defense Forces recruits. Harefuah, 123, 73–8. Ska˚rderud F. (2007). Eating one’s words, part I: ‘Concretised metaphors’ and reflective function in anorexia nervosa – An interview study. Eur Eat Disord Rev, 15, 163–74. Steinberg S, Tobin D, Johnson C. (1990). The role of bulimic behaviors in affect regulation: Different functions for different patient subgroups? Int J Eat Disord, 9, 51–5. Swirsky D, Mitchell V. (1996). The binge-purge cycle as a means of dissociation: Somatic trauma and somatic defense in sexual abuse and bulimia. Dissociation, 9, 18–27. Warin M. (2009). Abject relations: Everyday worlds of anorexia. London: Rutgers University Press. Waters A, Hill A, Waller G. (2001). Bulimics’ responses to food cravings: Is binge-eating a product of hunger or emotional state? Behav Res Ther, 39, 877–86.
ORIGINAL ARTICLE
Binge eating as a meaningful experience in bulimia nervosa and anorexia nervosa: a qualitative analysis Karin Eli
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Institute of Social and Cultural Anthropology, University of Oxford, Oxford, UK
Abstract
Keywords
Background: Clinical studies describe binge eating as a reaction to hunger, negative affect, or the need to dissociate. However, little is known about the meanings that women with bulimia nervosa and anorexia nervosa associate with binge eating. Aims: To examine how women with anorexia nervosa and bulimia nervosa interpret their experiences of binge eating. Methods: Sixteen women who engaged in binge eating and had been diagnosed with anorexia nervosa, bulimia nervosa, or their subclinical variants were interviewed about their experiences of eating disorder. Interview data were analyzed using phenomenologically-informed thematic analysis. Results: Participants described binge eating as a practice through which the self experiences a sense of release, and existential emptiness is replaced by overwhelming fullness. Conclusion: Meaningful experiences of release and fullness are central to binge eating in bulimia nervosa and anorexia nervosa, and may contribute to the long-term maintenance of this practice.
Anorexia nervosa, bulimia nervosa, eating disorders, lived experience, qualitative analysis
Introduction Binge eating is a defining feature of bulimia nervosa, and is a common feature of anorexia nervosa (APA, 2013). Several clinical studies have analyzed binge eating as a response to hunger, negative affect (stress, anxiety, and low self-esteem), or a need to dissociate (Engelberg et al., 2007; FullerTyszkiewicz & Mussap, 2008; Heatherton & Baumiester, 1991; Steinberg et al., 1990; Swirsky & Mitchell, 1996; Waters et al., 2001). Other studies have positioned binge eating within a larger cycle of emotional mediation, wherein the binge episode is preceded by negative mood, and the eventual purge functions as emotional ‘‘regulator’’ (Alpers & Tuschen-Caffier, 2001; Cooper et al., 1988; Lynch et al., 2000; Powell & Thelen, 1996). While these studies offer differing hypotheses on binge eating, all suggest that binge eating is emotionally, physiologically, or socially ‘‘functional’’ (Davis & Jamieson, 2005; Jeppson et al., 2003), facilitating a temporary transition from negative to positive states. While eating disordered practices are functional, they are also existentially meaningful. Medical anthropologists have examined embodied meanings of self-starvation in anorexia nervosa, highlighting how values such as asceticism and purity shape anorexic people’s lived experiences (O’Connor & Van Esterik, 2008; Warin, 2009). Binge eating, however, Correspondence: Karin Eli, Institute of Social and Cultural Anthropology, University of Oxford, 51-53 Banbury Road, Oxford OX2 6PE, UK. E-mail: [email protected]
History Received 12 August 2014 Revised 17 December 2014 Accepted 21 December 2014 Published online 18 May 2015
has not been similarly investigated. Interview-based analyses have focused on participants’ contrasting of bulimia nervosa and anorexia nervosa (Burns, 2004), discussions of bulimic practices as self-victimizing, abject, and shameful (Brooks et al., 1998; Broussard, 2005), or use of binging and purging as a means to physiological, emotional, and social ‘‘wellbeing’’ (Jeppson et al., 2003). Still, little is known about the meanings that women with bulimia nervosa and anorexia nervosa ascribe to binge eating. In light of recent work suggesting that misconceptions about eating disorders hinder effective treatment seeking and referral (Mond, 2014; Ra¨isa¨nen & Hunt, 2014), and that gaps between clinical concepts and patient experiences may form a barrier in mental health care (Black et al., 2014), this study aims to elucidate how patients interpret their binge eating experiences.
Methods This study analyzes accounts of binge eating narrated by 16 women (18–38 years old at first interview) who had anorexia nervosa (with bingeing and purging symptoms), bulimia nervosa, or their subclinical variants (eating disorder not otherwise specified [APA, 2000]). The 16 participants were interviewed as part of a larger, longitudinal medical anthropology study (n ¼ 36) concerning the subjective experience of eating disorders in Israel (2005–2006 and 2011). The larger study also included participants who had restrictive anorexia nervosa and participants who practiced purging only (without antecedent binge eating); these participants were excluded
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from the present study. The analysis relies on the interviews conducted in 2005–2006, as the 2011 interviews focused on processes of chronicity and recovery, and elicited participants’ reflections on experiences they described in the study’s first phase.
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Study setting Israel has been of interest to eating disorders researchers due to its ethnic and religious composition, sizable populations of recent immigrants, and ongoing armed conflicts. These attributes, as some researchers have argued, set Israel apart from its European and North American counterparts, making it a testing ground for the impact of Westernization on the development of eating disorders (see Latzer et al., 2008). Indeed, Israeli public health studies concerning disordered eating have emphasized comparisons across ethnic, religious, and native-born/immigrant sub-populations, with the aim of determining which groups are at greater risk for eating disorders (Latzer et al., 2008). Going beyond the Westernization concept, medical anthropologists have argued that eating disorders in Israel are influenced by locally specific experiences and values, including compulsory military service (Eli, 2014) and the framing of motherhood as a path to women’s ‘‘good’’ citizenship (Gooldin, 2002). As Gooldin (2002) argues, eating disorders in Israel may be ‘‘glocal’’, interweaving Western and Israeli values. Estimates of the prevalence of eating disorders in Israel rely on informal observations by local experts, who cite rates similar to those found in Western Europe and North America (Rabinovitch, 2011). Epidemiological research on eating disorders in Israel is scant, with only a few early studies conducted among limited populations (e.g. military recruits [Scheinberg et al., 1992]). To date, no comprehensive population-based study concerning the prevalence of eating disorders in Israel has been published. Studies utilizing
eating attitudes questionnaires (such as EAT-26) among nonclinical samples suggest that disordered eating attitudes and practices are prevalent among young Israeli women (Latzer et al., 2008). Most major eating disorders treatment centers in Israel are government-subsidized, and managed by the Ministry of Health or Israel’s Kupot Holim (non-profit healthcare funds); private treatment options, however, are also available. While some of this study’s participants sought private treatment for eating disorders, most received treatment in Kupot Holim or Ministry of Health outpatient clinics and inpatient wards. Participants The sample of 16 included six women who had bulimia nervosa, four women who had anorexia nervosa (including one with past bulimia nervosa), three women who said they had anorexia nervosa and bulimia nervosa simultaneously, two women who identified as having a non-specific eating disorder, and one woman who had concurrent, conflicting diagnoses of bulimia nervosa and anorexia nervosa. All women received treatment for their eating disorders, and were diagnosed by clinicians: nine were treated in outpatient settings only, and seven were treated in inpatient and outpatient settings; 12 participants were receiving treatment at the time of first interview. The participants’ duration of eating disorder ranged from 1 year to 23 years; their duration of binge eating practices ranged from under 1 year to approximately 16 years (Table 1). All participants were Israeli and Jewish. At the time of first interview, nine participants had a university degree or pursued university studies, six participants had completed secondary education, and one participant had less than 10 years of education. Eleven participants completed their compulsory military service; the remaining five were exempt due to their mental health status and other reasons.
Table 1. Summary of participant eating disorder characteristics.
Participant ID
Gender
Age at first interview
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Female Female Female Female Female Female Female Female Female Female Female Female Female Female Female Female
21 25 38 31 18 20 26 20 23 38 25 37 31 21 22 26
a
Eating disorder diagnoses (in adulthood)a
Estimated age at eating disorder symptom onsetb
Estimated duration of binge eating practices (in years)c
In treatment at the time of first interview
BN EDNOS BN AN and BN AN AN EDNOS AN and BN BN (past AN) AN (sub-clinical; past BN) BN AN and BN BN AN and BN AN BN
16 16 12 19 17 19 20 12 15 15 17 17 14 15 18 16
5 9 16 8 51 51 3 51 7 6 8 10 16 6 4 8
Yes Yes No No Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes
Diagnoses were self-reported by the participants. Estimated age of onset was self-reported by the participants. In some cases, the participants’ self-reported age of onset preceded their age at clinical diagnosis by several years. Some participants described dietary restriction as their main eating disorder symptom at onset, with binge eating appearing months or years later. c Estimated duration of binge eating practices is based on the participants’ narratives of their eating disorder histories. b
Binge eating as a meaningful experience
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Recruitment Participants were recruited through an outpatient eating disorders clinic (n ¼ 7), an online pro-recovery eating disorders discussion board (n ¼ 6), and an informal chainreferral network (n ¼ 3). The participants recruited through chain-referral were initially contacted by the study’s key participant; those who were recruited through the clinic were initially contacted by a member of the clinical team. After they had indicated interest in the study to their ‘‘mediator’’, and had agreed to share contact details, the author contacted the potential participants by telephone, explaining the study, answering any questions they had about participation, and then asking if they might wish to participate. To recruit participants through the eating disorders discussion board, the author posted three messages with information about the study, and invited readers who wanted additional information to contact her through the discussion board’s messaging system. The author communicated with those who expressed interest in participating through message exchanges and telephone conversations, following a process similar to the one described above. Ethics The first phase of the study was approved by the author’s university’s ethics committee (June 2005), and was also approved by an Israeli Kupat Holim Helsinki Ethics Committee (August 2005). The second phase of the study was approved by the author’s university’s ethics committee (February 2011) and did not require Helsinki ethics approval. The participants provided written consent for this study. All names used in this article are pseudonyms, and identifying details have been concealed or altered to ensure confidentiality. Data collection The study relied on in-person semi-structured interviews. The interviews took place in locations the participants selected, usually their homes, parks, or cafes. The author, a medical anthropologist, opened the majority of interviews by asking, ‘‘when and how did it begin?’’ – a question that framed the participants’ illness narratives. While the author explored the participants’ experiences of eating disorder through similar follow-up questions, aimed at addressing several key topics (e.g. body image, perceptions of food), the selection of follow-up questions, question order, and phrasing varied according to each participant’s narrative. This approach enabled the emergence of participant-led accounts, reflecting their varied histories, modes of expression, and experiential foci. The author respected the participants’ narrative choices, and only questioned them about experiences of binge eating after they had mentioned this practice. Data analysis The interviews were digitally recorded and transcribed, and supplemented with written notes. As the study was designed to focus on participants’ experiences and interpretations thereof, data were analyzed using phenomenologically-informed thematic analysis (Braune & Clarke, 2006). A phenomenological
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orientation was chosen to emphasize the participants’ subjective experiences and the meanings they assigned to them; the thematic analysis approach enabled the identification of patterns of experience and meaning across the sample. The author extracted and collated the interview sections that concerned binge eating, and carried out an initial coding of the extracts for participants’ experiences and interpretations of binge eating. She used the emergent codes to guide a de-novo analysis of the entire corpus for overarching subthemes, and then used a spreadsheet to record which subthemes occurred in each interview, ensuring their accurate representation in the analysis. Subthemes that expressed similar experiential patterns (e.g. binge eating associated with a sense of compensation, release, or excitement) were brought together to develop the two larger themes this article explores. The author defined and named these themes according to the central meaning participants associated with the experiences they captured (e.g. compensation, release, and excitement could all be defined under ‘‘binge eating as embodied release’’). All quotes used in this article were translated by the author from the original Hebrew. During the translation process, the author noted Hebrew phrasings that could not be translated directly (e.g. ‘‘going up’’ for gaining weight). The participants’ descriptions of binge eating experiences had direct counterparts in English.
Results Binge eating as embodied release Binge eating practices were related to the sensation of hunger itself, and to the experience of practicing dietary restriction, both past and present. Participants described binge eating as effecting embodied release from restrictive practices, using the words ‘‘liberating’’, ‘‘compensatory’’, and ‘‘exciting’’. Some participants described binge eating as an immediate, uncontrollable response to prolonged hunger. For example, Aline, who began to practice binge eating after months of restricting anorexia, said: ‘‘I had those breaking points when I would just devour everything I see around the house’’. Others, like Orit, described binge eating as a planned climax following a period of self-starvation: ‘‘succeeding [in carrying out a binge] was definitely exciting’’. However, the hunger to which the participants referred extended beyond the immediacy of present-day associations, and encompassed memories of past starvation. Hadas, who began to practice binge eating after she was hospitalized for anorexia nervosa, spoke of binge eating as a liberating experience. Seven years after recovering from anorexia nervosa, Hadas was undergoing a recovery process for bulimia nervosa, and continued to struggle with her binge eating practices: I’m still trying to satiate the hunger I created in myself then. (. . .) It’s not like during the entire [anorexic period] I didn’t want to eat – I wanted to eat, but I was in the prison, like, I couldn’t eat even when I wanted to, even when I was, like, dying of hunger, I couldn’t allow myself to eat. (. . .) [T]his release is so much fun, the food, suddenly you discover what a pleasure it is, how much it’s, how much you’ve missed it, you just can’t stop.
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Hadas interpreted the emergence of her binge eating practice as driven by both physical and emotional restriction, wanting nourishment and ‘‘pleasure’’, and thus conveying her need for food for both survival and life. The sense of release associated with binge eating, however, was linked not only to the sensation of hunger, but also to the sense of being controlled, even subjugated, by restrictive dietary practices. While participants associated restrictive practices with feelings of willpower and control, restriction also emerged as compulsive, punishing, and oppressive. Mirah, who engaged in binge eating and purging for over 15 years, used the metaphor of a ‘‘well-oiled German machine’’ to describe herself during bouts of starvation. Ma’ayan, who engaged in binge eating for about 3 years, said she felt there was a ‘‘monster [that] sat inside [her] head’’, inflicting a Nazi-like starvation regime ‘‘like they did to the Jews in the concentration camps’’. Both women alternated days of starving with days of binge eating. Although Mirah said she often felt humiliated by her binge eating, she also described bingeing as ‘‘a sensation of freedom and excitement’’, saying: ‘‘it was actually who I was (. . .) the binges, it was the most authentic thing I had in life’’. For Ma’ayan, binge eating was a way of allowing herself, following bouts of starvation, ‘‘to taste, like, all the things there are in the world, before she [the monster] decides I’m not eating anymore’’. Through using highly loaded imagery related to the Holocaust, both Mirah and Ma’ayan conveyed a sense of being incarcerated, coerced, and even dehumanized by their own restrictive practice. ‘‘Filling up’’ an existential emptiness Binge episodes often began with sensations the participants described as ‘‘abnormal’’ hunger, overwhelming cravings, or a frightening/disquieting emptiness. Participants described their binge episodes as directed at the sensation of intense, overwhelming fullness. Some described rummaging through the entirety of their kitchens, consuming combinations of food they considered otherwise inedible, and bingeing unto exhaustion to achieve the fullness they sought. Tamar, who engaged in binge eating and purging for more than 15 years, said she continuously shopped for food during binges to maximize fullness: I had to reach a condition where my stomach already really ached, it was already – I couldn’t put [food] in, but I put more and more and more in. (. . .) I sat stretched, with nausea already, it was clear that there’s already no space for anything, but I’ll eat another packet of biscuits and then, like, reach the edge. For Tamar, as for other participants, the sensation of pain induced by binge eating was both the signal and the embodiment of sought-after fullness. The need for ‘filling up’ was in continuous dialogue with the sensation of emptiness. Galit, who engaged in bingeing and purging practices for about a decade, said that, during a binge ‘‘[you eat] until you feel that you’re being torn, that you can’t move anymore’’, an experience she interpreted as ‘‘responding to some emptiness’’ and ‘‘existential problems’’.
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Angie, who engaged in bingeing and purging for 6 years, explained that her binge eating used to occur only when she felt deep emotional pain; over time, however, it became part of her ‘‘routine’’, a method to cope with ‘‘quietness’’. This ‘‘quietness’’ was so unbearable that she practiced cycles of bingeing and purging, sometimes repeatedly, despite suffering from hypokalemia and other life-threatening complications: Many times it happens to me that then, very quickly I, like, feel the emptiness again, and then I have to fill up again. Like, sometimes it really, like, for hours upon hours upon hours, like, eating, vomiting, eating, vomiting, eating, vomiting. Until I’m exhausted already and I go to sleep. The need for a binge, she said, was ‘‘stronger than [her]’’; the emptiness would drive her out of bed at night, through bouts of severe insomnia, leading to a disturbing sense that she had no ‘‘other things in life’’ but food. The underlying emptiness, as the participants described it, was an ambiguous, ongoing, and unsettling sensation. Adi, who engaged in bingeing and purging for about 8 years, said that bulimia was her ‘‘anchor’’, and that she used to carry food in her bag to feel security and warmth: ‘‘The emptiness always frightened me. The emptiness meant beginning to cope with things as they are’’. Adi said she dreaded the sensation of hunger, the rumbling of an empty stomach; she was afraid of not having food at her disposal and not being able to soothe the emptiness inside. The emptiness she feared, however, extended beyond hunger: That same void in the stomach, as far as I’m concerned, is allegorical to that same void that you feel in the soul. (. . .) I really didn’t find anything that’s so close to a sensation of satiety, to a satiety from life, because I never reached this satiety from life itself, from the doing itself, from what I’m achieving in life. And from food – yes. Food – I ate, I was satiated, I vomited. Adi later said her binge eating was an act of ‘‘devouring the entire world’’. Her many professional aspirations had all dissipated, and as one disappointment followed another, she felt increasingly dissatisfied. Food, however, being simple and material, could offer an immediate (if temporary) alleviation of gnawing emptiness. As succinctly described by another participant, Shiri, who spoke longingly of binge eating after 8 years of eating disorder, food provided the ultimate – and perhaps the only – means to contend with emptiness: ‘‘It’s something that, nothing else ever filled me up like that, like the food did, [and] I don’t think anything [else] ever will’’.
Discussion The experiential meanings of binge eating, as the participants described them, were grounded in embodied sensations. While binge eating emerged in response to dietary restriction, it was not merely a hunger for food that this practice addressed. Rather, as the participants described it, binge eating was related to sensations of release or fullness (with some participants evoking both). These themes were consistent with findings described by Jeppson et al. (2003), who
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reported on participants for whom binge eating was a physiological, sometimes euphoric, ‘‘release’’ from dietary inhibitions (p. 123), and quoted one participant who said binge eating filled the ‘‘emptiness’’ of feeling ‘‘hungry for love’’ (p. 121). In the present study, the sensations of release and fullness were sought-after responses to experiences of restriction and emptiness. Notably, release and fullness had both felt and cognized dimensions: while these sensations were intensely embodied through the process of ingesting food and accompanied by experiences such as excitement or pain, they were also metaphors for existential states. The release participants felt through binge eating was an active, bodily response to the ongoing experience of being restricted, or ‘‘imprisoned’’. Likewise, the fullness achieved through a binge was an overwhelmingly felt response to states of emotional emptiness. These findings suggest that experiences of binge eating constitute a metaphoric, embodied expression and negotiation of existential states. In the participants’ accounts, emotion and bodily sensation were inseparable; food and eating practices thus provided a literal expression of states of being, such that, for example, the sense of existential emptiness could be literalized and (temporarily) negated by the ‘‘filling up’’ process of a binge. The use of metaphors among women with anorexia nervosa has been noted by Ska˚rderud (2007, p. 168), who calls attention to the sensation of emptiness, drawing links ‘‘between the physical act of emptying the stomach and bowels, and clarifying one’s mind’’. Women with anorexia nervosa, argues Ska˚rderud (2007, p. 163), equate the physical and the emotional through bodily ‘‘concretized metaphors’’, revealing a compromised ‘‘symbolic capacity’’. However, eating disordered practices are not mere reflections of pathology: they implicate socially salient values and courses of action. In her analysis of anorexic being-in-theworld, Warin (2009) argues that anorexic practices of restriction and purging are rooted in culturally meaningful anxieties about avoiding abjection, preventing contagion, and maintaining cleanliness. Viewed through this lens, the practices this study’s participants described were embedded in normative discourses of empty and full lives, and in associations of starvation with the Holocaust and imprisonment. For the participants, the metaphoric linking of existential and binge-related experiences was visceral, articulated first, and primarily, through the immediacy of bodily sensations. Kirmayer (1992, p. 339) argues that the ‘‘bodily grounding of metaphor’’ is central to the experience of illness. Through bringing together culturally recognized meanings, the ailing body, and individual perceptions, metaphoric expressions situate expressions of illness within frameworks of sense-making (Kirmayer, 1992). As other anthropologists have argued, emotional expression itself links the sensory and the symbolic (Boellstorff & Lindquist, 2004). Emotion, argues Lyon (1995), is profoundly felt; grounded in the body, it implicates both individual sensory experiences and the social environments that inform them, such that mental, bodily, and social dimensions cannot be separated. As an example, Lyon (1995) cites Lakoff’s (1987) contention that metaphorical and physiological expressions of anger are
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interlinked – ‘‘being hot with anger’’ is, quite literally, embodied. The feeling body, then, lives and communicates experience through culturally meaningful idioms. ‘‘To be anxious’’, writes Leavitt (1996, p. 515), ‘‘is to have a feeling associated with meaning’’. In the participants’ accounts, the bodily and the existential could not be disentangled: physical emptiness not only symbolized existential emptiness, but also constituted its very embodiment. As the participants experienced and articulated persistent distress through concepts related to food and eating, their binge eating practices held felt meanings that could contribute to the long-term maintenance of their eating disorders. Clinical implications The findings suggest that existing clinical models of bulimia nervosa and anorexia nervosa can be strengthened by including the experience of binge eating as a potential disorder maintaining factor. In the most influential model of bulimia nervosa – Fairburn et al.’s (2003) cognitive-behavioral theory – binge eating is conceptualized as a response to deviations from dietary restriction: the model frames dietary restriction as driving the disorder, with binge eating maintained through its mediating effects on mood and reinforcement of psychopathology. Although cognitive-behavioral therapy (CBT-BN) is the most effective treatment for bulimia nervosa, it is only moderately successful; as Fairburn et al. (2003, p. 515) note, this may reflect the model’s incomplete accounting for disorder ‘‘maintaining mechanisms’’. Fairburn et al. (2003) offer an enhanced model (CBT-E) that includes maintaining mechanisms such as ‘‘clinical perfectionism’’ and ‘‘mood intolerance’’ (p. 509), alongside the core ‘‘overevaluation of eating, body shape and weight’’ (p. 510; see also Murphy et al., 2010). However, while this model accounts for the mood regulation effects of binge eating, it does not address patients’ valuation of binge eating experiences. This study’s findings demonstrate that, in their descriptions of binge eating as ‘‘release’’ and ‘‘fullness’’, participants defined binge eating not as the corollary of a more meaningful dietary restriction, but as a valued practice unto itself. Indeed, while they endorsed ideals of dietary restriction and thinness, many participants described binge eating as their disorder’s core practice. This suggests that treatment models should include the experience of binge eating as a possible maintaining mechanism. Such conceptualizing of binge eating as a driver of disorder would potentially allow clinicians to devise treatment for patients whose disorder mechanisms are not captured in the extant, dietary restrictionfocused models. Limitations All participants were women, and all but one had completed secondary education, such that the representativeness of the sample is limited. Further research is needed to determine whether men, children, and women of lower educational attainment who engage in binge eating ascribe similar meanings to their practices. Additionally, as this study’s participants engaged in compensatory practices, future studies should explore the meanings that people diagnosed with binge
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eating disorder ascribe to binge eating. Of the larger study sample (n ¼ 36), a few participants chose not to discuss binge eating despite having engaged in this practice. The analysis may be limited, therefore, to participants who were ready to speak about binge eating experiences with a researcher, although it is possible that participants did not discuss binge eating because they perceived this practice as less salient to them at the time of interview. Moreover, as participants selfreported their diagnoses, discrepancies between assigned and reported diagnoses are possible. It should also be noted that data collection and analysis were conducted by a lone researcher; while this is common practice in anthropology, it precluded obtaining inter-coder reliability. Finally, although data were translated carefully, some linguistic nuances cannot be translated directly from Hebrew to English.
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Conclusion While undeniably functional, binge eating has important existential meanings for people with bulimia nervosa and anorexia nervosa, and should not be conceptualized as a mere means to an end. As this study showed, participants articulated ongoing states of adverse feeling through metaphoric meanings related to food and eating, with words such as ‘‘emptiness’’ and ‘‘imprisonment’’ used to express distress. Such meanings provided fertile ground for habitual engagement in binge eating, which was conceptualized and experienced as ‘‘filling up’’ and ‘‘releasing’’. Addressing meanings of binge eating and their antecedent feelings in treatment could prove useful, particularly where long-term binge eating practices are concerned.
Declaration of interest The author has no conflicts of interest to report. The second phase of the study was supported by a grant from the Oxford University Press John Fell Research Fund.
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