Eating Disorders are a mental illness that affects an individual’s ability to have a healthy relationship with food and their bodies. Anorexia, Bulimia, Binge Eating Disorder, and Other Specified Feeding and Eating Disorders are prevalent psychiatric diseases that can be life threatening. In fact, eating disorders have the highest mortality rate of any psychiatric illness. About 20% of individuals who struggle with these disorders die from medical complications or by suicide (Hudson, Hiripi, Pope, and Kessler, 2007).
Prevention and early intervention are critical with these disorders; however, even those who have struggled for decades are able to recover with the help of trained professionals. Effective treatment can be conducted in an outpatient setting, in an inpatient or residential setting with the level of care needed by the patient based on the active symptomology, severity, and duration of the disorder.
Anorexia Nervosa is categorized by an intense fear of gaining weight, a distorted body image, denial of the severity of the illness, and a weight that is lower than expected for the individual. Persons suffering from Bulimia Nervosa engage in recurrent binge eating (consuming an excessive amount of food in a short time) followed by self-induced vomiting, laxative abuse, excessive exercise, and/or fasting. This disorder also has an extreme focus on weight and shape, but unlike individuals who struggle with Anorexia, those who have Bulimia will often be of average, or even higher weight.
Binge Eating Disorder exhibits similarities to Bulimia, in that recurrent binge eating episodes take place, but differs because no compensatory behaviors subsequently occur. The binge eating episodes are often when the person is alone, the person eats even when not hungry, and food consumption goes past the point of feeling comfortable.
Some physiological and psychological complications of eating disorders are abnormal sleep patterns, difficulty concentrating, preoccupation with food, weight, and shape, panic attacks, social isolation, mood swings and irritability. Eating disorders are often difficult to assess and are not always readily detected by others. Those who struggle with these illnesses are often very secretive and shameful about their behaviors and will go to great lengths to hide what they are doing. They often function very well in their lives and are frequently successful high achievers. Also, with the normalization of disordered eating patterns in today’s society, eating disorders can go unnoticed and be minimized in severity.
Who is Affected?
Eating disorders affect all genders, races, socioeconomic classes. They can develop at any age and impact not only the individual who has the diagnosis, but the entire family system. Family therapy is a crucial part of treatment, particularly if the struggling individual resides at home. Eating disorders often place much strain on the family system and support for the family members is not only helpful for them, but in turn, also helps the patient receive better support from their loved ones.
Temperament, genetic predisposition, cultural, and environmental factors, can all contribute to the development of an eating disorder. Those who suffer from an Eating Disorder often have other co-occurring disorders. Anxiety, Depression, Substance Abuse, Obsessive Compulsive Disorder, and PTSD are just a few of the other diagnoses observed in this patient population. Many of those who have an Eating Disorder have also experienced some form of abuse. Sexual, physical, and emotional abuse is rampant in this patient population and is a core issue that needs to be addressed for the individual to fully recover. Studies estimate that 74% of eating disorder patients have experienced abuse (Brewerton, 2008).
The type of trauma and the mediating factors, such as developmental phase, self-image at the time of the trauma, family support, and ability to process the trauma at the time of the event, all contribute to the level of integration or level of dissociation that the individual has with the traumatic event. The higher level of dissociation or the inability to integrate the trauma in a healthy manner, the more likely that the individual will resort to unhealthy coping mechanisms to mitigate the effects of the trauma.
It’s Not About the Food
Having suffered abuse often creates much emotional turmoil and shame, which if left unresolved can trigger the need to use eating disorder behaviors in an attempt to avoid uncomfortable feelings. It’s inappropriate to just treat the symptoms of an eating disorder, so we often find ourselves saying to patients, “It’s not about the food!” Perfectionism, over-functioning, the avoidance of feelings, unresolved grief, and feeling out of control, are some examples of therapeutic work that must be undertaken to enable the individual to let go of their need for maladaptive behaviors.
It is not uncommon for individuals who have an eating disorder to also struggle with substance abuse. Rates of substance abuse in this population are estimated to be 12-18% for those who struggle with Anorexia and 40-45% for those who struggle with Bulimia and Binge Eating Disorder. Treating both the eating disorder and the substance abuse simultaneously is imperative to a successful recovery.
Managing symptom substitution and the development of other negative coping behaviors is crucial.
When starting the treatment process, therapists often talk about the game of Whack-a-Mole, the arcade game where a soft foam bat is used to hit moles that pop up only to have others pop up in different holes. When patients start to address one symptom, the clinician and patient need to remain vigilant to recognize other symptoms that may begin to appear or reappear. Trading symptoms is just another form of avoidance and inhibits the recovery process.
Substance abuse can also contribute to the adoption of eating disorder behaviors. For example, one of my patients restricted her food intake and over-exercised as a way to counter the calories she was taking in from her alcohol use. Both the use of substances and the eating disorder served as a way for her to disconnect from the grief she was avoiding.
Just as a therapist must be cognizant of the severity of eating disorder symptomology and the potential medical complications that may arise with these behaviors, the clinician must also be aware of the level of physiological dependence that the patient with substance use disorder may present when starting treatment. It is impossible to begin any meaningful treatment while under the influence of substances and medical attention may be needed to help the individual address any issues of withdrawal.
Treating Eating Disorders
As mentioned, treatment settings vary based on what the individual will need to be successful in starting their recovery process. The first step is finding a clinician who specializes in treating this specialty population. Once a trusting relationship has begun with the therapist and/or the treatment facility, the initial step in treating trauma in eating disorder patients is to stabilize and manage the maladaptive responses, such as restricting, bingeing, purging, or other compensatory behaviors.
Psychotherapy is not as effective if an individual is in active addiction, both with an eating disorder and substances. The normalization of brain function through nutritional stabilization is critical to begin the therapeutic work. Refeeding, or normalizing meal patterns, significantly alleviates anxiety and regulates mood. It allows anti-depressants to function properly and allows psychological issues to be fully assessed. Due to the chaos disordered eating can have on the body and brain, it is vital to first nutritionally stabilize an individual before one can fully determine full treatment planning.
Entering a higher level of care can help a patient stabilize their eating disorder. With the support of trained professionals, they can safely address the underlying reasons for their eating disorder. When an individual has experienced abuse, an adaptive function of the maladaptive eating disorder behavior is to provide a sense of control. Patients often look for ways to hold onto some sense of power in their lives. They create discipline around food and/or exercise, hyper control around their bodies, and the predictability and structure takes them out of the chaos that they internally or externally are experiencing. Managing food intake becomes much easier than managing or processing emotions regarding abuse that occurred. The eating disorder can be used by the individual to feel seen and heard when they feel they have not had a voice. Becoming emaciated or obese are very visible ways that pain can be physically observed. I have frequently heard stories of an individual discharging tension and anger that they have toward their perpetrator through purging. There is an aspect of wanting to feel “clean” or “empty” that individuals who have experienced sexual trauma try to create by restricting their food intake, using laxatives and/or diuretics.
I cannot reiterate enough how the underlying factors of the eating disorder must be addressed to help the patient achieve full and long-lasting recovery. While helping a patient achieve nutritional stability is vital, it is not sufficient to create recovery.
One patient, Sally, came into treatment having been to multiple other facilities that were fantastic at helping her stabilize her eating disorder behaviors; however they did not process her trauma. Consequently, after treatment, her underlying traumatic memories would resurface making her unable to cope with her emotional distress, thereby triggering her regression back to using her eating disorder behaviors to cope with her unresolved trauma. This left her feeling both increasingly defeated and hopeless, and in a cycle of entering treatment centers where she was unsuccessful at achieving a full and long-lasting recovery. Intensive trauma work, while simultaneously addressing her eating disorder behaviors, was the necessary key to help Sally work through her pain and fully heal.
Trauma processing through somatic experiencing, narrative story-telling, and other trauma treatment modalities helped her heal the hurt and pain that had burdened her for so long. A pivotal moment came during psychodrama group, where she was able to give voice to her wounded and traumatized child part. Sally was able to say to her perpetrator what she wished she could have said both as a child and now as an adult. She regained her power and was able to unburden feelings of anger, guilt, and shame, which she had held onto for years. Sally’s interpersonal relationships improved once she engaged with a more empowered sense of self. I was able to witness Sally move from operating in the world from a “less than” position to feeling more positively about herself. Once her trauma was processed, she was fully able to connect with herself and with others. Overcoming her apprehension and fear she once again connected with her body, which she had previously avoided since her childhood abuse. Establishing this connection allowed her to learn how to meet her emotional and physical needs. Addressing the underlying factors that contributed towards her need for her eating disorder was the only way Sally was going to be able to maintain recovery and live the life of which she is worthy and deserves to enjoy.
The Goals of Therapy
The goal of therapy is to take the rejected and disconnected parts of self and work to form an authentic whole. When a person experiences traumatic events they often disconnect, split, and separate from their wounded and hurt parts of self. They avoid feeling the feelings that they deem as being, “too much,” or, “overwhelming.” As clinicians, we help individuals process the emotions that have often been repressed or ignored, allowing them to be fully present and engaged in the world. By addressing underlying issues, they can operate in the world without the need to avoid or distract and subsequently they find their life more meaningful and their relationships improved.
Post Traumatic Growth
I love the concept of Post Traumatic Growth. The premise of this theory is that through adversity and struggle we can become more connected with ourselves, with others, and with our bodies. If an individual allows themselves to fully engage in the process of working through their struggles, whether they result from trauma, addiction, or attachment issues, the person connects with a level of self-awareness and enlightenment that many others do not make the effort to achieve. I find this to be especially true when applied to those living with eating disorders, addiction, and/or trauma.
Robert Frost says, “The only way out is through.”
The beauty about having struggle is that if we are willing to muster up the strength to face our adversity, we can come out stronger. To be clear, “stronger” does not mean tougher; in this case, it is the sense that we can face the world in a more connected and meaningful way. Recovery is being mindful and engaged. It is being connected in a way that is impossible when the eating disorder or addiction is taking the lead or the trauma responses are primary. Through recovery, people realize that as they step away from their destructive coping behaviors, they can embrace life with a new view and a new way of relating to others. They make the time to connect more with their feelings in the treatment process, allowing them to fully engage in the world in an emotionally regulated way. When an individual processes the way they are responding to the world and their environment, they automatically become more connected with their sense of self and often deepen their values and belief system.
When a person can let go of the need to hold onto a sense of control, they can begin to blossom in a world where they previously felt out of control. They become more in tune with their thoughts and feelings. With this new perspective, they can thrive. There is a sense of gratitude towards the body that develops; a person recognizes they are a human being not a human doing. The person can often identify feelings of strength and self-resilience that they have never felt before. Patients that leave treatment often find new interests that they had never spent time and energy to consider; they sometimes establish a new life path, they re-evaluate priorities, and true healing occurs. Not only that, but when a person works through a traumatic event, they often find themselves better able to withstand future struggles.
Psychological stress, whether a trauma, addiction, or an eating disorder, is an opportunity for an individual to flourish. It is an opportunity for the individual to take something destructive and negative, and process it so that it can be used to re-establish oneself in the world in a different way, one that is more meaningful and resilient.
Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biological Psychiatry, 61(3), 348–358.