Why isn’t overeating an eating disorder?

My very first peer-reviewed manuscript was back in the early 2000’s, and wasn’t a study. It was a discussion paper comparing anorexia nervosa to a new proposed psychiatric disorder which was to be named, “Muscle Dysmorphia”. This proposed disorder was popularized by the book, “The Adonis Complex” in which the authors suggested that an emergent pattern of disordered thinking was becoming more prevalent amongst men. This disordered thinking was defined as the preoccupation that one was not muscular enough, and manifested itself in obsessive-compulsive-like behaviour (e.g. compulsion to go to the gym, or significant distress when one was not able to go to the gym) as well as possible self-harming behaviours, such as not participating in social activities because of one’s workout or diet routine, or use of anabolic or other performance-enhancing drugs for the purposes of getting more muscular (I’m not going to debate whether taking anabolic steroids is considered “self-harm” behaviour; it is, however, an example of such in the proposed criteria.)

My position on the proposed “Muscle Dysmorphia” remains unchanged. I do not feel it belongs in the DSM in its current state, largely due to the subjective criteria for its proposed diagnostic criteria, which depends entirely on whether the diagnostician feels the patient is already “muscular enough”.

However, recent events got me thinking back to my original manuscript. I had originally written the first incarnation of the paper in my undergrad when I took a life-changing course in my final year entitled, “Critical Issues in Medical Epistemology” in which we examined the social construction of disease from a historical point of view. At the time, the first papers on “muscle dysmorphia” had not yet been written, so I had written about what I also thought was an emerging phenomenon which had casually been referred to as “biggerexia”, or “reverse anorexia” in some of the popular and sparse academic literature.

Epistemology is the study of how we gain knowledge. By social construction, I’m referring to how a disease entity evolves to become “known”; not just from its biological origins and cluster of symptoms and signs, but inevitably its assigned “source”.  Broadly speaking, sources come from “within” and “without”. For a few years before HIV was isolated, AIDS was thought to be a disease that came from “within”. Now, we largely think of AIDS as being caused by an external agent, though there is still a small group of scientists that believes otherwise.

In January of this year, I decided to commit to a physical transformation. During my transforming time (arguably, I am still transforming), what struck me as remarkable was the kinds of comments people around me gave me. Many were complimentary, which was flattering, but some alluded to the idea that I wasn’t behaving in a healthy manner. “You’re wasting away,” was a common one. And because I work in an environment where I am quite close to my colleagues, people noticed when I was fasting, and commented that it wasn’t healthy. This experience has been reported by many of my fitness colleagues and their clients as well (though, this is all anecdotal.)

While we recognize obesity as a health problem today, what strikes me as odd is the fact that there has been virtually no “pathologicalization” of the behaviour of overeating (other than “food addiction” which is a whole other topic–Can you, in fact, be addicted to a substance you need to survive?) We are, in fact, more likely to label undereating as disordered than we are overeating. Overeating is, in fact, culturally sanctioned in North American culture, particularly around social events and holidays. It is even celebrated (admittedly, “Man vs Fasting” just doesn’t have a sensational pitch behind it.) Undereating is part of some religions, but is largely sporadic, with some exception of some religions advocating weekly or annual, or seasonal fasting. It is otherwise, not that socially acceptable to eat less, or to simple occasionally not eat at all.

However, if we examine overeating as a potential pathological behaviour, it exhibits criteria for a disorder:

1) A substantial amount of time is spent on eating, such that a pre-specified time of day is scheduled and mandated by many labour laws to accommodate this behaviour due to its overwhelming prevalence.

2) A substantial amount of money is spent acquiring excessive calories, despite understanding the consequences of chronic overeating.

3) Eating behaviour continues despite sufficient caloric intake, and/or feelings of satiety, independent of energy requirements to perform daily activities, or even periodic heavy activity.

4) Unchecked by subsequent caloric deficit, it inevitably leads to harm: Heart disease, vascular disease and liver disease being the most direct, with linkages to other diseases such as some forms of cancer.

5) Ongoing overeating behaviour can cause marked anxiety and significant stress on self-image and self-perception.

6) People continue to engage in the behaviour despite knowing the consequences for its continuation.

In the right context, almost anything can be explained in a disease model, including love. This is not to make light of an anorexia or bulimia diagnosis, or true body dysmorphic disorder or obsessive-compulsive disorder.  I’m not advocating that overeating be classified in the DSM as a psychiatric disorder, but with some of the negative attention that one receives while trying to make, or demonstrate a positive change, it does make me think a bit more on why it is that pursuing a leaner, even a more muscular body might make it onto the official list of psychiatric disorders before eating more than you need to does.

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