What are eating disorders?
Eating disorders are a subset of serious, yet treatable mental health concerns that affect people of all different identities including gender, race, ethnicity, socioeconomic status, religion, age, body type, weight and shape.
- Anorexia Nervosa. A disease characterized by the limitation of food or caloric intake with the intention of weight loss. Individuals experience a preoccupation with body weight, shape and/or size and often engage in various behaviors to promote weight loss or to change their appearance. There are two subtypes of this disorder, one in which the individual focuses heavily on restriction of food and fuel intake (and often over-engaging in exercise and other weight loss behaviors) and the other in which the individual may experience true and/or subjective binges and subsequently compensate for this behavior through methods such as purging or laxative abuse.
- Bulimia Nervosa. A disorder in which individuals experience a cycling between binge eating and compensatory behaviors including purging (self-induced vomiting), laxative abuse, exercise, diet pills, etc.
- Binge Eating Disorder. A disorder characterized by recurrent binge episodes or the eating of large quantities of food typically very quickly and without the ability to stop or regulate their food intake until they reach a point of physical pain or become sick. Often described as feeling out of control in relation to food and typically without any compensatory measures associated as seen in Bulimia Nervosa.
- Body Dysmorphic Disorder. A disorder in which an individual experiences intrusive and persistent thoughts and preoccupations with an, often perceived, “flaw” in one’s appearance.
- Avoidant & Restrictive Food Intake Disorder. Previously referred to as “Selective Eating Disorder”, it is a limitation of food intake that is not associated with body image distress, a drive for weight loss or fears associated with fatness, body shape or body size.
- Rumination Disorder. A disease categorized by the rumination (re-chewing, re-swallowing and spitting out) of food.
There are also diagnoses which include an “Other feeding & eating disorder” which is meant to encapsulate serious disorders that do not meet full criteria for the above mentioned diagnoses or where the symptoms cross over a multitude of diagnoses.
Additionally and though not considered formal diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), other terms often used in the diagnosis and assessment of eating disorders include “Diabulimia” (a disease in which people intentionally give themselves less or stop taking their insulin for the purpose of weight loss), “Night Eating Syndrome” (a disease wherein an individual has a dysregulation of their circadian rhythm which impacts sleep, mood and food intake) and “Orthorexia” (a disease categorized by an obsession with “healthy” eating).
What is the difference between an eating disorder, disordered eating and body image distress?
Many people will start to learn about eating disorders and assume that they have one as a result of their experiences with dieting, body image distress and/or disordered behaviors with food. While in many cases a diagnosis may end up being warranted, it is important to note that we exist in a culture that perpetuates idealized body types, is heavily influenced by the diet and fitness industry and associates weight and size with health, it is difficult for anyone not to develop some disordered ways of eating or relating to their body. The pressure to be ‘enough” can be overwhelming.
What do we mean by that? Eating lies on a spectrum of “ordered” to “disordered” with more seriously disordered eating leading to a formal eating disorder diagnosis. Someone who experiences disordered eating may engage in eating disorder behaviors (restriction/dieting, binging, purging, etc) as well as have psychological distress around their food intake, appearance and weight/body shape. Remember, eating lies on a spectrum so it is important to address disordered eating directly and as early as possible to prevent the possibility of developing a full-blown eating disorder and to help interrupt some of these unhealthy coping skills and thought patterns.
It is also important to note that body image distress is a serious and significant part of many people’s life experiences and in many cases can be a risk factor for the development of an eating disorder. Note that not everyone with body image distress will warrant this diagnosis and it is important you feel you can make space to talk about this distress and address it in therapy.
How do they develop?
There is still a lot to know about the development of an eating disorder but we know that there seems to be biological, psychological and sociocultural factors that play into it. We often talk about development in association with risk and contributing factors. Some of these include:
- Having a family member with an eating disorder (active or in recovery).
- A history of dieting and/or a “Negative Energy Balance” or essentially burning off more calories or fuel than you are taking in. This may include dieting and other weight control methods as well as intensive sports and athletic training, growth spurts and/or illness which can all result in that negative balance and subsequently trigger the development of disordered eating and/or an eating disorder.
- Brain Activity. This includes lower frontal and temporal lobe activity which can lead to unregulated behavior and a diminished fear response respectively. In addition, low levels of serotonin can lead to increased anxiety and obsessive thinking which is a common trait of people experiencing eating disorders.
- Type 1 Diabetes. Research has found significant correlations between Type 1 Diabetes and eating disorders. See “diabulimia” above.
- Negative Body Image. See above.
- Rigid and/or fixed thinking. Common within this would include “perfectionism”.
- Co-occurring anxiety disorder.
- Trauma. This may include direct traumatic experiences and/or historical and intergenerational trauma. In particular, trauma of any kind that involves the body (ex. Sexual or physical abuse) has an increased association with the development of an eating disorder.
- Sociocultural values & norms. This includes the beliefs and values of the culture you exist in — specifically around food, body types, and body image.
- Biological sex and gender identity. This includes the socialization around male and female bodies including appearance, role, and expectation. There is also increased risk associated with people who identify as transgender.
- Sexual orientation. Non-heterosexual individuals are at an increased risk of developing an eating disorder and/or engaging in risky weight control behaviors. While continued research is being done to better understand the correlation between these two pieces, it is assumed that much of this is due to cultural norms and standards.
- Family norms around food and bodies. What you have learned about food and your body growing up shapes much of your values and beliefs about food as an adolescent and adult.
- Diet Culture & Fat phobia. The overvaluing of thin bodies in our culture and weight stigma as well as the massive role the diet and fitness industry has in shaping our culture and beliefs about ourselves. These billion dollar industries control much of the messaging we receive
- The desire to “fit in” and the idealization of bodies and people. This includes the pressure to act and look a certain way to fit into a cultural ideal and norm. It is important to note that acculturation is a major factor to consider in this and that many minority groups find themselves trying to acculturate and assume the norms of the “dominant” culture.
- Media & Technology. There is increased risk in mental health distress associated with the amount of time on social media as well as the content consumed. Compounding concerns include the unregulation of material, the prominence of filtered and edited imagery that perpetuate idealized body types, dieting and standards of living and more.
Please note that these experiences cannot predict an eating disorder will develop, only allow us to better identify and respond to risk. The more we can identify potential risk factors in advance, the greater likelihood we have at prevention and/or early intervention. Subsequently, the better we can understand these underlying developmental factors, the better we can support the client in their recovery and create a treatment plan that is specific to their needs and experiences.
How can therapy help someone experiencing an eating disorder?
The treatment of an eating disorder traditionally involves more integrated care including the support of a therapist or other mental health provider, a dietitian or other nutrition counselor, and a medical provider so that you can address any medical and physical health concerns, help create a more balanced relationship with food and ensure adequate food intake, and address the underlying psychosocial concerns.
Specifically, mental health treatment often includes psychotherapy and, in some cases, medication. Therapy is beneficial to address the underlying stressors and trauma associated with and contributing to the eating disorder, manage stressors and trigger situations and help the client work through unhelpful thought, feeling and behavior cycles that are connected to their eating disorder. Identifying the developmental factors and triggers is key to helping work through various stuck points and also develop skills to more effectively deal with past, present and future stressors including people, circumstances and experiences without engaging in your eating disorder. While evidence supports a variety of treatment modalities in the approach and treatment of eating disorders, some of the more common approaches include Cognitive Behavioral Therapy (CBT; or a more specific approach for eating disorders called CBT-e), Acceptance & Commitment Therapy (ACT), and Dialectical Behavioral Therapy (DBT). A newer modality entitled Radically Open DBT has also been shown to be effective and is becoming a more prominent approach to working with people with eating disorders. And finally, Family-Based Treatment is an evidence based treatment in treating children and adolescents with eating disorders.
It is also important to note that treatment can occur at various levels and degrees of intervention including outpatient, intensive outpatient, day treatment, inpatient and residential care. Matching the appropriate level of treatment to the severity of the diagnosis is incredibly important to help ensure appropriate care and support.
How can I be sure a therapist has training and experience working with eating disorders?
The best thing you can do to be sure a clinician is the right fit for you is to “interview” them. This may include reading their bios, setting up a consult appointment, asking for referrals and feedback from other trusted sources, and meeting them face to face. It is important to note that research has shown that rapport (or the relationship you build with your therapist) is one of the most important factors in determining successful treatment outcomes. At Trellis, we want to make sure you find the right fit for you which includes not only finding people with the expertise you are looking for but someone you connect with. That being said, did you know that Trellis Counseling has several clinicians on staff with dedicated training and experience working with eating disorders? Contact us today to set an appointment and to learn more about them!