Introduction

Binge eating disorder (BED) is characterized by frequent episodes of uncontrollable eating without compensatory behavior (American Psychiatric Association, 2013). Although BED is presumed to be the most frequent kind of eating disorder, with a global prevalence estimated at 0.9% (Erskine & Whiteford, 2018), it is an understudied diagnosis compared to other eating disorders such as bulimia nervosa (BN) and anorexia nervosa (AN). The research on BED is mainly comprised of studies of prevalence, and very little of the research aims to broaden the qualitative understanding of BED. Kornstein et al. (2016) claim that the knowledge of BED, in general society, is low and that treatment is often poorly (or not) provided. The lack of research on the field seems to reflect the overall knowledge and treatment of BED. The aim of this article is thus to gain deeper insight into qualitative aspects of BED.

Mentalizing is a framework for understanding and treating eating disorders, which links symptoms of eating disorders to struggles with certain emotional, social, and cognitive skills (Luyten et al., 2020; Gagliardini et al., 2020; Skårderud et al., 2012, 2020). Although mentalizing is an increasingly popular framework, the focus mainly seems to be on disorders like AN and BN. There seems to be a gap in the literature on how mentalizing can be applied to broaden the understanding of BED. With mentalizing as a theoretical framework, this article aims to gain insight into the emotional, cognitive, social, and cultural aspects of BED. In addition to the diagnostic criteria for BED (American Psychiatric Association, 2013), the data applied in this article is based on three semi-structured interviews with women who have previously been diagnosed with BED. Based on this, we have developed the following research question: “How could mentalizing be applied to understand binge eating disorder?”

Mentalizing

Mentalizing involves creating meaning to the actions of oneself and others, by implicitly or explicitly interpreting behavior as an expression of emotional and mental processes (Fonagy et al., 2002). The quality of one’s ability to mentalize is connected to whether one can relate to, and distinguish between, an inner and outer perception of reality (Fonagy et al., 2002). When there is a high degree of mentalizing, one can acknowledge consciously or unconsciously that inner states are subjective representations of reality and not objective truths. In this way, mentalizing helps us to not act directly on affective impulses, rigid thought patterns, or social misunderstandings. Mentalizing could be regarded as a prerequisite for the perception of a stable and free self and as a necessary tool to help us navigate a socially complex world (Fonagy et al., 2002; Skårderud et al., 2012).

Mentalizing as Psychological Transformation

Lecours and Bouchard (1997) illustrate mentalizing as a mediator between the intuitive and bodily aspects of the self and the rational and organized parts of the self. Through inner representations (mental images and verbal representations) and symbolizing (the ability to abstract reflection), mentalizing is understood as a transformation from isolated somatic sensations to gradually more complex mental processes. In this perspective, mentalizing unites the body and the mind and helps us to reflect beyond concrete and affective experiences. For example, anxiety could be experienced as a bodily sensation of discomfort. This sensation could through inner representations be transformed into mental content with the term “anxiety” as a mediator. Symbolizing makes us able to reflect on how and why the anxiety occurs, as well as find a solution. Mentalizing through inner representations and symbolization enables us to recognize pre-linguistic bodily signals, as containing important cues regarding our psychological needs or desires, as well as reflect upon them, ultimately helping us to act more constructively (Lecours & Bouchard, 1997).

Mentalizing and Developmental Psychology

While Lecours and Bouchard (1997) emphasize the bodily aspect of mentalizing, Fonagy et al. (2002) address how mentalizing could be understood through the lens of developmental psychology. They put forth that the potential for internalizing inner representations of oneself and others is found through engaging in intersubjective relationships, particularly experiences with mirroring and affective mirroring.

Mirroring involves the activation of brain neurons intended to establish a connection with others. These mirror neurons activate both when an action is performed and when observing someone else perform the same action (De Luca Picione et al., 2022). Psychoanalyst Donald Winnicott argues that the potential of becoming aware of oneself and one’s inner states lies in mirroring. He claims that when the child looks at the mother’s face “he finds himself,” as the mother’s expression toward the baby is intricately linked to what she sees (Winnicott, 1971, p 151).

Affective mirroring refers to the mirroring process where emotions are both directly experienced and indirectly observed (De Luca Picione et al., 2022). Affective mirroring can occur when the caregiver acknowledges and mirrors the child’s emotional state (Hart, 2011). When the child’s inner states resonate with the caregiver’s emotional and behavioral expression, their bodily rooted experiences can become consciously accessible for the child (Fonagy et al., 2002). The child’s feelings are thus no longer merely physically embedded but made available as internal mental representations (Fonagy et al., 2002; Lecours & Bouchard, 1997). These experiences of mirroring contribute to the construction of the child’s identity and intersubjective frameworks.

In a secure intersubjective relationship, there lays also the opportunity for the child to imagine and reflect upon the mental state of others, which can enhance their capacity for symbolic thinking (Fonagy et al., 2002). Intersubjective interactions can also contribute to establishing an integrated separation between the mind of oneself and others, as well as stimulate emotional and social competencies (Fonagy et al., 2002). The lack of intersubjective relationships and experiences with affective mirroring can impair the ability to develop inner representations and symbolic thinking, as well as social and emotional skills that are prerequisites for mentalizing.

Mentalizing and Culture

In addition to attachment relationships, our emotional, social, and cognitive states are influenced by global and cultural factors (Jørgensen, 2001). While psychoanalytic literature primarily focuses on mirroring in the context of infants, the concept of mirroring/failed mirroring extends to cultural dimensions as well (Schaller, 2008). From a cultural developmental perspective, society, much like in attachment relationships, has the potential to serve as a mirror for individuals to construct their identities and self-understanding. Similar to Winnicott’s idea that a child sees itself when looking at the mother, society’s perception of the individual significantly contributes to shaping one’s identity. Moreover, failed mirroring can be considered a cultural phenomenon when social representations are assumed and projected (Schaller, 2008). In such cases, the societal reflection may not accurately represent the individual, impacting their identity construction, as well as emotional and cognitive skills/functioning.

One can in this perspective argue that marginalization or a lack of social acknowledgment of one’s inner states could hinder one’s ability to create accurate inner representations and therefore affect one’s ability to mentalize. Societal and cultural tendencies (e.g., trends and norms) can be internalized and manifested as psychopathological symptoms (Bäärnhielm et al., 2010). For example, a social norm that understands obesity as being purely linked to laziness can hinder the individual’s development of alternate and potentially important representations for understanding one’s excessive eating habits. These are representations that could play a crucial part in their emotional and existential well-being.

Mentalizing and Eating Disorders

The mentalizing approach to eating disorders relates symptoms to impaired mentalizing through pre-mentalizing modes (Fonagy et al., 2002; Skårderud et al., 2012). These modes are psychic equivalence, pretend mode, and teleological stance and are all characterized by imbalances in the experience of psychological reality.

In a mode characterized by psychic equivalence, the world is perceived only from one’s own experiences, without recognizing alternative realities (Fonagy et al., 2002). One’s subjective perception of the world lacks a representative quality, and beliefs and feelings are therefore perceived as a direct reflection of the world. In such a mode, there is no distinction between inner and outer reality (Hart, 2011). As an illustrating example, people with eating disorders can experience themselves as being obese, despite being medically underweight (Skårderud et al., 2020). Their mental picture of themselves as being overweight bears more merit in their perception of reality than objective facts, such as numbers on the scale.

Pretend mode involves a detachment from both inner subjective reality and physical reality, and one can experience a feeling of being disconnected from one’s self and others (Fonagy et al., 2002). Such a mode may come to light in different ways. Most relevant for people with BED is dissociation during a binging episode, where a loss of control and detachment from one’s own body and mind may leave the subject completely unaware that they are binging. In extreme cases, the dissociative state may prove so severe that the subject has no recollection of the episode (Skårderud et al., 2020).

Teleological stance involves an exaggerated physical-objective understanding of oneself and others (Fonagy et al., 2002). In such a mode of functioning, one lacks inner representations and mainly relates to physical and external reality (Fonagy et al., 2002). Actions are not understood as a result of inner/subjective conditions or motives but are solely seen as actions (Skårderud et al., 2020). In such a mode, the psyche is not experienced as a mediating variable that can affect behavior, and consequently, the experience of subjectivity and oneself as a “mental agent” may be lacking (Fonagy et al., 2002). In people with BED, this could involve a lack of understanding that binge eating is connected to emotional and psychological processes.

Alexithymia

In addition to the pre-mentalizing modes, alexithymia is a trait linked to impaired mentalization and is significantly associated with eating disorders, including people with BED (Pinaquy et al., 2003; Skårderud et al., 2020; Westwood et al., 2017). Alexithymia refers to a lack of connection between the mind and emotional signals and involves a lack of contact with, and words for, bodily signals, as well as an impaired ability to symbolical thinking. Alexithymia can therefore be linked to poor emotional regulation and can lead to an external-oriented mentalization style (concretism) which are all traits linked to eating disorders (Skårderud et al, 2020).

Methods

In addition to the theoretical approach and diagnostical criteria (American Psychiatric Association, 2013), we also apply data from three qualitative, semi-structured interviews. The interviews contained questions related to how the informants perceived themselves, their emotions, their body, social relationships, and symptoms during the period they had BED. Since emotional, social, and cognitive processes are considered dialectical, the interview guide is not divided by these themes, but by self-oriented and other-oriented mentalization. The interview guide is formulated with open questions to capture the informant’s descriptions of experiences, for example, Can you describe a binge eating episode? In the interviews, specific questions were also asked, for example, Did you have a language for your feelings during the period you had BED? The study is evaluated by The Norwegian Centre for Research Data (Sikt) and satisfies requirements for the protection of human subjects in research. An important note regarding the data for this study is that it should be considered anecdotal due to the small sample and how the data was collected (for a master’s thesis at the Department of Special Needs Education, University of Oslo).

Informants

The sample consisted of three females ages 26–40 who had previously had BED. Two of the informants had overweight as a symptom, and two still struggled with episodes of relapse but no longer had a clinical diagnosis. To strengthen validity, the criterion for participating was that the informants no longer had BED. This is because a mentalizing-based approach to psychopathology relates symptoms to impaired mentalization (Skårderud et al., 2012), and an ongoing binge eating disorder could have limited the ability to answer the questions in the interview. At the same time, the fact that the informants no longer have BED is not a guarantee that their descriptions in the interviews are valid. The informants in the study described experiences from periods that were potentially characterized by pre-mentalizing ways of functioning, as some of the informant’s symptoms started during school age. Descriptions of functioning can thus be rooted in inner beliefs that do not necessarily have roots in external reality (Fonagy et al., 2002), which may impair validity. The data, therefore, limits itself to saying something about the informants’ subjective descriptions of their ability to understand themselves and others during the period they had BED. We apply the acronyms I1, I2, and I3 to the informants.

Data Analysis and Results

Interviews were audio-recorded. The recordings were later transcribed and analyzed through thematic analysis (Braun & Clarke, 2006). Our thematic categories had their point of departure in theoretical conceptualizations related to mentalizing, especially the terms linked to impaired mentalizing. These conceptualizations were analyzed in light of the totality of the interviews, resulting in social context as a contextual theme.

Although the interview guide did not have such a focus, a recurring theme during the interviews was how the informants experienced being treated and understood by the outside world. They pointed to how their close relationships, the healthcare system, and cultural and social narratives painted a picture of their symptoms in a way that led to a feeling of shame in the informants. After analyzing and categorizing the interviews to the theoretical descriptions of mentalizing, we found that they did not resonate with the overall impression from the interviews. Therefore, we choose to include a theme related to the informants’ description of the social context. We experience such a contextual backdrop as necessary to understand informants’ descriptions of social, emotional, and cognitive functioning during the period they had BED.

Results and Discussion

The themes, sub-themes, and theoretical descriptions are presented in Table 1. As the results from the study are mainly applied as anecdotal, we present results and discussion in the same section.

Table 1 Themes, sub-themes, and theoretical descriptions
Full size table

In the following, we present anecdotal quotes from the results to discuss the research question.

Binge Eating Disorder in a Social and Cultural Context

Reas (2017) claims that compared to the general public, people with BED receive more negative attention and are often perceived as weak, lazy, and irresponsible. Hollett and Carter (2021) indicate that stigma related to BED is primarily attributed to food-related behavior (binge eating) and not weight. The informants also reported receiving negative attention and that their difficulties with food were by others interpreted as a result of laziness, stupidity, and lack of willpower, as opposed to their binge eating being a psychologically and emotionally rooted issue.

I1 described it in the following manner: “You are just lazy, that is what I heard. Fat people are lazy.” A possible explanation for people with BED receiving more negative attention could be what Duesund (1995) understands as a cultural tendency. She illustrates how the body is reduced to an object that is to be disciplined, examined, and picked apart. In this perspective, food is no longer solely a necessity for living but a core aspect of our identity. Duesund (1995, s. 18) exemplifies this by saying “Tell me what you eat, and I will tell you who you are.” In a Western culture characterized by greed and abundance, dieting could be seen as a symbol of self-control, discipline, and morality (Skårderud, 2004). BED and symptoms like being overweight could become an expression of the opposite, namely, poor morality and a lack of self-control. A cultural context where one’s relationship with food and body becomes a metaphor that defines a person’s value and abilities could be understood as an externally focused mentalizing style (concretism). Such a way of functioning is characterized by an unintegrated psychological reality, where reality is experienced through concrete expressions (Skårderud et al., 2020), in this case through binge eating and overweight.

The informants expressed how treatment against BED solely focused on dieting and weight loss. Only addressing the physical symptoms in the treatment of BED could be understood as a Cartesian attitude, where physical aspects are seen as separate from the mind (Brean, 2015; Duesund, 1995). Such an objectified and somatic approach to BED disregards that the informants’ difficulties can involve more than physical behavior and that bodily symptoms could be related to emotional, existential, and psychological factors. From a mentalizing perspective, this kind of approach could be interpreted as a teleological attitude. Teleological attitude involves a way of functioning where there is an exaggerated focus on physical aspects (Skårderud et al., 2020). BED being understood and treated primarily as a somatic and physical difficulty could contribute to fewer receiving proper treatment seeing as several of those with BED are not overweight.

An alternative reason why people with BED receive more negative attention may be that episodes of binge eating are something many people in modern and prosperous societies have experienced. Therefore, it is easy to project one’s understanding of binge eating. For example, if one perceives that eating excessively or gaining weight in their personal life is connected to laziness and lack of willpower, one could be at risk of understanding the symptoms of BED in the same way. This could be understood as psychological equivalence, which is a state where one is unable to distinguish between the inner realities of oneself and others (Fonagy et al., 2002). This kind of cultural/socially rooted understanding of binge eating could be related to BED being an under-communicated and unknown diagnosis in healthcare and general society (Blodgett Salafia et al., 2015; Kessler et al., 2013). People can thus lack knowledge and alternative representations of the difference between binge eating and a binge eating disorder.

The discussion of the social and cultural approach to BED could be understood as a society characterized by collectively impaired mentalizing, linked to psychological equivalence, concretism, and teleological attitude. These characteristics of the social and cultural context are crucial for understanding BED and the informants’ descriptions of BED. In the following, this will be applied as a contextual backdrop for understanding the informants’ descriptions of BED.

Inner Confusion

The informants reported that they, in the period with BED, struggled to understand their emotions and put them into words. I2 stated, “I did not know why I felt all the things I did. I did not know what it was and how to cope with it.” In the descriptions of how the informants experienced their own emotions, words like “being numb,” “discomfort,” and “chaos” were used. I3 described it in the following manner: “I have not been able to put my emotions into words […] It is a very restless feeling, a feeling of discomfort and unease in the stomach.”

Based on the informants’ descriptions, they seem to be lacking inner representations and the ability to symbolic thinking related to their bodily rooted emotions. This inner confusion could be coherent with alexithymia, which involves a lack of contact with emotions and an inability to express emotional experiences (Skårderud et al., 2020; Taylor, 1997). In accordance with the informants’ descriptions, research shows that people with BED score significantly higher on tests related to alexithymia compared to the general population (Pinaquy et al., 2003; Westwood et al., 2017).

The informants’ perception of other people interpreting their symptoms because of stupidity and laziness could have strengthened their inner confusion. Two of the informants described how they succumbed to a narrative that their symptoms were a result of a lack of willpower, which did not resonate with how they experienced BED themselves. I3 described it in the following manner:

It was not until 2019 I understood that it was an eating disorder. Until then, I thought that losing weight was the solution and that it was about lacking willpower that, I was weak, and all the other things other people told me. But when I look back on it now, this does not make sense as my willpower is strong, and I do a lot of stuff that is very difficult […] That is why it is so strange that I bought into the story that it (binge eating) was related to a lack of willpower.

For the informant, it could seem like society’s interpretation of their symptoms weighed heavier than their own understanding of their symptoms. The societal portrayal of binge eating projected onto the informant could be seen as a form of failed mirroring (Schaller, 2008). Lack of experiences with one’s subjective perspective being recognized by others could lead to detachment from inner states (Fonagy et al., 2002; Hart, 2011). The consequence is poorer self-oriented mentalization, which prevents the ability to be in contact with and take into account bodily signals that may be important for our existential and emotional well-being. Failed mirroring, through the lack of alternative cultural representations, could have resulted in the delegitimization of the informants’ experience and a further strengthening of alexithymic functioning.

Regulation of Emotions: The Dys-appearing Body

A dys-appearing body involves a bodily state characterized by discomfort that demands our conscious attention and hinders free expression (Duesund, 1995). This bodily state is opposite from the ecstatic body which is a state of free unfoldment, which indulges in being and forgets the body. In the dys-appearing body, the body steals all our attention. As an example, a splinter could lead to bodily discomfort and dys-appearance of the body, which disrupts the free being. Related to not understanding bodily and emotional states, the informants described how emotions were perceived as an unidentifiable bodily disturbance. I3 described it in the following manner: “I have not been able to put my emotions into words […] It is a very restless feeling, a feeling of unrest and anxiety in the stomach.”

Such bodily unrest could be understood as a dys-appearing condition. As opposed to a splinter (which could easily be removed), the solution is not necessarily as obvious when an alexithymic functioning and a dys-appearing emotional state occurs. The informants described how binge eating helped regulate emotions. They described episodes of binge eating as a form of high or a distraction from emotions. One could claim that emotions in people with BED present themselves as bodily dys-appearance and binge eating could be understood as a dysfunctional strategy for coping and regulating this emotional discomfort.

Impaired regulation of emotions could be a core aspect of all eating disorders and is also a transdiagnostic factor for difficulties with mental health (Skårderud et al., 2020; Svaldi et al., 2012). It is also specifically correlated with BED (Dingemans et al., 2017).

Psychological Reality

In the following, we touch upon some areas within the concept of psychological reality. These are (a) perception of symptoms, (b) body, (c) self-concept, and (d) social self-concept.

Perception of Symptoms

When asked how the informants perceived their symptoms, I1 described how she did not have any inner awareness of binge eating. She stated, “I used to say: I do not eat that much, so it is weird that I am looking this way […] I do not think I noticed it (the binge eating episodes) myself.” The informant’s description of how she did not register the episodes of binge eating could be understood as an imbalance in her perception of psychological reality in pretend mode, where one is disconnected from both inner and outer reality (Fonagy et al., 2002).

Another informant described how she regarded herself as no longer sick due to losing weight, even though she still experienced frequent episodes of binge eating and other symptoms. Her perception could be understood as a teleological attitude, where the world is experienced through physical and concrete expressions (Skårderud et al., 2012). Her definition of being healthy was determined by losing weight and not her emotional or psychological state. There exist several ways of interpreting this kind of psychological functioning. Lack of connection with (and understanding of) emotional states (alexithymia) could have led to weight being a concrete metaphor for well-being. Skårderud et al. (2012, p. 58) claim that “when the psychological reality is poorly integrated, the body gets an exaggerated role in defining who one is.” We can also interpret this way of functioning as culturally anchored. The informants’ descriptions of how the outside world understood and treated their difficulties as a somatic issue could have affected their understanding of BED. The informants’ teleological attitude toward their symptoms might therefore be interpreted as an internalized social/cultural representation of a teleological and dualistic attitude.

Body

One of the informants described how she perceived herself as physically small due to feeling small and invisible. I1 described it in the following way:

I could look at myself in the mirror and think that I was not that big but when I see pictures from that time, I can see that I was very overweight. I felt small and that I was a small, invisible, human being. Others could tell me that I was big but I did not feel big.

The informant’s description could be interpreted as a mode of psychological equivalence. The emotional experience of being small may have projected onto external reality and resulted in her experiencing her body as small. The same informant also described how she used clothes that were too big, which strengthened her perception of being small. Such an action could be rooted in a need to create coherence between inner and outer reality, in this case, the gap between intrapsychic perception and the physical world. Such a concretistic action would then function as an outer manifestation of an emotional experience of being small (Skårderud et al., 2020). Another informant described how she consciously denied being overweight. In her case, it may seem like it was not due to a lack of ability to mentalize, but rather an unwillingness to relate to her physical appearance.

The informants’ different understandings of their bodies mark a distinction between the ability and willingness to mentalize (Skårderud & Sommerfeldt, 2008). Such a distinction could be relevant regarding how one in mental health encounters people with BED. If it is rooted in an unwillingness, it could be useful to work with the mechanisms that are relevant to psychological self-defense. In the context of a society that “looks down upon” the overweight body, such a denial could protect own self-worth.

Self-concept

All the informants described how their symptoms defined their self-value and identity in different ways. I2 described it in the following way: “[…] it was the thought of not being worth anything because I could not control what I ate.” In addition, I2 pointed out that being overweight felt “synonymous with being stupid […] One cannot be fully informed when one cannot stop eating in a way that is not good for you.”

The informants’ descriptions of how characteristics, skills, and self-value were defined by the size of their body and eating habits could be understood as concrete mentalizing. Skårderud et al. (2012) relate concretistic thinking to teleological attitude, where people with eating disorders often change their bodies, aiming to improve their self-concept and self-worth. Seen in a broader social context, this is not necessarily a trait solely linked to eating disorders, but a culturally rooted tendency. As previously mentioned, people with BED experience social stigma and devaluation due to their external symptoms, which could affect their self-concept. The concretistic and dualistic attitude in society could have worked as the only available mirror for understanding oneself. This could lead to those with BED having no other alternatives for interpreting their symptoms and therefore being forced to internalize a cultural understanding that might encourage a feeling of shame and negative self-concept. The informants’ seeming teleological attitude toward their bodies is not necessarily related to impaired mentalization. It can in some ways indicate a high degree of mentalizing because they understand and follow the cultural norms and premise for social value. The goal here is not to draw any hasty conclusions that such concrete thinking is necessarily impaired mentalizing. It is rather to avoid directly concluding that the trait seemingly understood as impaired mentalizing is not necessarily about a lack of ability but should be considered in light of cultural and social aspects.

Social Self-concept

All informants described a fundamental assumption that others did not like them. Among the descriptions were “I thought everyone hated me” and “everyone thought I was fat, ugly, and horrible.”

In the interviews, the informants described having an idea that everyone disliked them and devalued them when they had BED. This could be understood as psychological equivalence, where one’s negative self-evaluation is projected onto others (Skårderud et al., 2020). At the same time, all informants addressed concrete experiences where they were judged and mocked because of their weight and relationship with food. The perception of being disliked and devalued could partly be seen as rooted in reality due to actual occurrences of rejection. Such a contextual understanding of the informants’ mentalizing traits could underline the importance of showing carefulness when assessing mentalizing abilities among those with BED. If one mistakenly interprets the thinking of others as detached from outer reality when it is not, it could strengthen inner confusion and alexithymia (Fonagy et al., 2002).

Conclusion

This article indicates that descriptions of BED could be connected to impaired mentalizing through alexithymia, pretend mode, psychological equivalence, teleological attitude, impaired regulation of emotions, and concretism. However, an isolated intrapsychological approach to mentalizing might overlook how cultural and social tendencies may affect one’s ability (or willingness) to mentalize. Traits of poor mentalization in people with BED are not necessarily isolated psychopathological symptoms but could be rooted in an internalized cultural impairment. By having an isolated approach to mentalization, we are at risk of misconstruing legitimate experiences of reality. There also seems to be a need for an alternative framework for understanding symptoms related to BED so that people with the diagnosis are not left to succumb to a culturally concretistic judgment of binge eating which may cultivate shame. Mentalizing could be a promising framework to promote a new language to understand oneself and one’s symptoms in a way that promotes self-understanding and self-worth.