Eating and food issues comprise a range of behaviors, such as overeating or undereating, that may or may not meet diagnostic criteria for an eating disorder. A diagnosable eating disorder occurs when one’s relationship to food spirals out of control, as is the case with anorexia nervosa, when a severe restriction of food results in dramatic weight loss, health complications, and even death, if left untreated. Eating issues generally occur because people develop complicated relationships with food or their bodies that might result in compulsive exercising and overeating or undereating, rather than allowing appetite and hunger to dictate eating cycles.
Disordered eating is a complicated matter; some people experience eating and food issues that become problematic or unhealthy even though they do not meet the specific criteria for one of the six eating disorders as outlined in the fifth edition of the Diagnostic and Statistical Manual (DSM).
The six specific types of eating disorders listed in the DSM-5 are as follows:
- Anorexia nervosa is characterized by extreme food restriction that leads to dangerously low body weight and possible malnutrition or starvation, among other detrimental physical effects. A person with anorexia is likely to have a distorted body image, fear gaining weight, and experience obsessive thoughts about food and weight. The DSM identifies two subtypes of anorexia: restricting type and binge-eating or purging type. The restricting type is the most common and may include restricting types of food ingested, maintaining extremely low caloric intake, or other rigid restrictions. The binge-eating or purging type includes severe restriction interspersed with periods of binge-eating or purging that may include compulsive exercising; self-induced vomiting; and/or the misuse of diuretics, enemas, or laxatives.
- Bulimia nervosa is identified as a cycle of binge eating that results in feelings of shame, guilt, and remorse, which further compel a person to compensate for the binge by purging or overexercising. Physical effects include dehydration, chronic sore throat or inflammation of the esophagus, abdominal pain, and bowel problems, among others. Bulimia does not generally result in significantly low body weight, and sometimes a person’s weight may be slightly above average.
- Binge eating is similar to bulimia in that a person will consume excessive amounts of food in a short period of time, followed by feelings of guilt or disgust. Purging, however, is absent from binge eating, though the person may engage in periodic dieting or fasting to compensate for the binge-eating episode.
- Avoidant/Restrictive food intake disorder (ARFID) is characterized by a routine failure to consume adequate nutritional or daily energy needs that results in significant nutritional deficiency, reliance on oral supplements or enteral feeding, significant weight loss (or poor weight gain in youth), or severely impaired psychological and social functioning.
- Pica is a relatively rare eating disorder that is characterized by the consumption of nonnutritive substances, such as clay, paper, soap, chalk, mud, or laundry starch. A person may be drawn to consume such substances due to the texture or flavor of the item, and the action of eating the substance may be self-soothing. Pica is more commonly found among specific populations, including adults with iron deficiency, pregnant women, institutionalized people, and children.
- Rumination disorder is the compulsive regurgitation of food followed by either spitting, re-chewing, or re-swallowing of the food, which does not occur as a part of another eating disorder or as a result of a medical condition.
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Many people choose to restrict their calorie intake or eliminate certain foods from their diet in order to lose weight, manage food allergies or intolerances, or cleanse their bodies. However, dieting may at times become extreme to the extent that it can damage a person's health. Examples of extreme diets might include those that severely limit calorie intake, eliminate entire food groups, or involve long periods of fasting.
It can be difficult to tell whether a diet is extreme or not. Some people argue for the benefits of fasting, cleansing, and eliminating certain food groups from their diet, and many individuals may be able to do so in a way that does not affect their health. But for others, extreme dieting might indicate the presence of disordered eating habits, which may become a serious concern.
Extreme dieting can have a negative impact on physical and mental health, as insufficient food intake may lead to decreased metabolism, digestive problems, the formation of gallstones, dehydration, malnutrition, increased stress, and decreased concentration and mental clarity.
While there is no clear distinction between a healthy diet and an extreme one, the following signs may indicate that a diet is too extreme.
- Decreased energy level. A significant lack of energy can indicate that calorie intake is too low.
- Constant thoughts about food. If an individual is thinking about food all the time and fixating on their food choices and consumption, it could indicate their relationship with food is becoming harmful.
- Difficulty sleeping. Disrupted sleep can signal that an individual is not eating enough or not getting the nutrients necessary for good sleep.
- Elimination of entire food groups. Each food group contains nutrients that are an important part of a balanced diet. While eliminating an entire food group, such as carbohydrates, from one’s diet can lead to weight loss, it can also leave an individual feeling hungry and deprived.
- Mood swings. Severely restricting calories can lead to anxiety, depression, and irritability.
- Changing social schedule. When a person begins to plan their life around their diet or declines social events because they do not want to eat, it may indicate that their diet is too restrictive.
Eating and food issues can develop from a wide range of psychological, biological, social, or external factors, and they affect people of all ages and genders, although adolescents and young women develop disordered eating habits at higher rates than other groups.
While cultural attitudes about weight and body size are not ultimately responsible for the origins of eating issues, they certainly provide a fertile environment for complicated issues with food and body image to flourish. In fact, in a culture that glorifies ultra-thin women and fixates on weight, body-mass index (BMI), and the latest diet trend, a disordered relationship with food, exercise, and one’s body can masquerade as “healthy.” People develop beliefs based on these shared but faulty cultural values that thinness makes a person desirable and worthy, and fat leaves a person undesirable and unworthy. Thus, food and eating issues are ultimately expressions of one’s sense of self and self-worth.
People who compulsively starve themselves, purge, eat to excess, or exercise excessively may do so out of feelings of anxiety, inadequacy, competitiveness, needing to please others, or low self-esteem. They may feel pressure to succeed and achieve perfection, particularly for those who work as models, dancers, actors, or athletes. Adolescents may be more susceptible to developing issues with food due to the hormonal, physical, and neural changes they experience; and sometimes stressful events, trauma, or troubled relationships can lead a person to develop an unhealthy relationship with food. A family history of eating issues or other mental health conditions may also contribute to a person’s potential for disordered eating.
Typically, recovery from disordered eating is a long and arduous process. Some therapies are relatively short term, requiring approximately four months, but when the process lasts for years, many people struggle with the motivation and energy required to commit to the work involved. It is important to recognize that recovery involves not just the absence of disordered thoughts and behaviors about food and body, but recovering one’s self—developing a sense of authentic identity, and cultivating self-acceptance and reverence for one’s self.
Many different types of psychotherapy have demonstrated effectiveness in treating eating and food issues, including interpersonal psychotherapy, cognitive-behavioral therapy, family therapy, and dialectical behavior therapy. In addition, many types of group therapy, acceptance and commitment therapy (ACT), psychodynamic therapies, and feminist therapies show promise for therapists who help people who want to improve their relationship with food and their bodies. When youth experience problems with food and eating, it is imperative to include parents in the treatment process.
According to Deborah Klinger, MA, LMFT, CEDS, “Psychotherapists who treat eating disorders in outpatient practice usually recognize the importance of adjunctive therapies and utilize resources such as dialectical behavior therapy (DBT) skills groups, group therapy, expressive arts therapies, yoga therapy, specialty yoga classes, and self-help programs such as Eating Disorders Anonymous.” Generally, food is the most important medicine and psychotherapy the best treatment, although sometimes medications are employed as needed to help control urges and stabilize mood.
In some cases, outpatient therapy alone is insufficient to treat the complexity of an eating problem. When a higher level of care or a more intensive treatment program is required, full-immersion treatment centers are available in the form of residential treatment centers or inpatient treatment in a hospital, for which a person resides in a treatment program facility for one month or longer. Other less intensive options include intensive outpatient, which requires participation in a day treatment center, or partial hospitalization, for which a person attends a hospital treatment program during the day.
Residential treatment centers often incorporate complementary modalities, such as yoga or tai chi, and experiential practices, such as equine-assisted therapy or art therapy into their treatment programs. Some residential treatment centers are modeled after the 12-step approach that originated with the Alcoholics Anonymous programs, and others use specific models of psychotherapy in their treatment protocol, like Internal Family Systems (IFS).
Anorexia and bulimia nervosa and binge eating are particularly dangerous eating disorders. Anorexia can lead to death from malnutrition or from refeeding syndrome, in which a sudden increase in nutrients causes an electrolyte imbalance that results in respiratory or cardiac arrest. The repeated vomiting associated with bulimia can cause esophageal rupture or electrolyte imbalances that may damage the heart, and binge eating can result in long-term health issues, such as high blood pressure, heart disease, obesity, or diabetes, among others.
Certified Eating Disorders Specialist Deborah Klinger, MA, LMFT, advises, “Patients whose disordered relationship with food is putting them in medical danger should have a treatment team that includes a primary care physician, a psychiatrist for overseeing medication, and a dietician who is skilled in treating eating disorders, as well as a psychotherapist.”
- "Perfectionist" personality type: Cathy, a 25-year-old medical student, came to therapy because some fellow students expressed concerns about Cathy’s extreme weight loss and increasing lack of participation in social events. Cathy maintains that she is simply stressed out about school, putting grades ahead of socializing. She has recently lost about 15 pounds, and at 5’4” and 96 pounds, her BMI is 16.5. She is menstruating regularly, though very lightly, and has been on birth control pills for the last four years. Further questioning reveals that Cathy was teased for being chubby in middle school, and she subsequently induced vomiting after meals for a few years. More recently, she has been cutting back on food portions, eliminating fats from her diet, and avoiding social events that include food. In addition to referring her to a physician for medical monitoring and a dietician for help devising an appropriate meal plan, Cathy’s therapist helps Cathy view anorexia as an unwelcome guest who has taken over Cathy’s brain. She helps Cathy challenge the distorted, anorexia-driven thinking about her body, and as Cathy’s eating improves and her brain is better nourished, she begins to acknowledge her tremendous fear of being less than perfect that stems in part from her parents’ intense focus on her academic achievements, rather than her inner emotional experiences. Cathy learned to ignore her emotional needs after her parents divorced, as they seemed happier when she did well in school.The therapist helps Cathy access her feelings and learn to manage painful emotions rather than starving them away, and Cathy becomes more comfortable in her body.
- Stress and self-hatred: Yvonne, 38, is an elementary school teacher who has always been overweight. She has tried innumerable diets, repeatedly losing weight and gaining it back. Ashamed of her lack of willpower, Yvonne soothed herself with food when her now-former husband made nasty remarks about her weight. After such a binge, she experienced remorse and vowed to be strong and disciplined from then on. She enters therapy because she feels defeated and wonders if she has a problem with emotional eating, although she fears this might just be an excuse for her weaknesses. Yvonne’s therapist explains the relationship between painful emotional states and the misuse of food as an antidote and provides Yvonne with tools for tuning into her body’s hunger and satiety signals to dictate her eating, rather than following a weight-loss plan. At the same time, the therapist teaches Yvonne to recognize the urge to overeat as a sign of emotional distress left unacknowledged. Through therapy, Yvonne recognizes the effects of her father’s alcoholism on her family and herself—she had unknowingly learned from her father to stuff painful feelings down. Yvonne developed the habit of reaching for food to comfort herself when her father was drunk and arguing with her mother, who was timid and did not argue back. As Yvonne’s eating became more in tune with her body’s needs and she developed greater emotional self-care skills, her body dropped much of the excess weight.
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