Eating & Food Issues

Disordered eating is a complicated matter. It comprises a range of behaviors and attitudes, including but by no means limited to those that meet the DSM criteria for eating disorders. Cultural attitudes about weight and body size are not responsible for the origins of eating disorders, but certainly give them a fertile environment in which to flourish. The DSM-IV names three main types of eating disorders: Anorexia Nervosa (with a Binge-Purge subtype and a Restricting subtype); Bulimia Nervosa, and Eating Disorder Not Otherwise Specified (ED NOS) which includes Binge Eating Disorder. 

Many individuals who struggle with disordered eating don’t meet DSM diagnostic criteria, but suffer from sub-clinical eating disorders, or varying degrees of a disordered relationship with food, body and self. Often a compulsive relationship with exercise is present as well. Eating and food issues that manifest as overeating or that cause weight gain are often mistakenly regarded as bad habits or lack of willpower.

• What Qualifies as an "Eating Disorder"?
• Genes or Environment - What Causes Eating Disorders?
• How Psychotherapy Can Help with Eating & Food Issues
• What Type of Therapy is Best For Treating Eating & Food Issues
• How Eating & Food Issues are Medically Treated
• DSM Criteria for Eating Disorders
• "Perfectionist" Personality Type Leads to Anorexia - Case Example
• Stress and Self-Hatred Causes Weight Gain - Case Example

What Qualifies as an "Eating Disorder"?

Eating and food issues are variants of overeating or under-eating, rather than eating in harmony with one’s body’s needs. Anorexia nervosa involves eating fewer than enough calories and nutrients to maintain one’s body’s normal weight and can involve compulsive exercise or bingeing and purging (compensating for calories ingested via self-induced vomiting, laxatives, diurectics, enemas) as well. Bulimia nervosa is binge eating followed by self-induced vomiting or other compensatory behaviors. Fasting and exercising are considered “compensatory behaviors” but not purging, so someone who binge eats and then eats nothing for 2 days after is considered to have the non-purging type of bulimia. The category ED NOS is a catch-all, which includes binge eaters and those who purge without eating what is considered by DSM criteria to be a binge. Other “styles” of overeating, such as compulsively grazing all day, are not included in the DSM classifications of eating disorders. ~ Overview provided by Deborah Klinger, MA, LMFT, http://www.pizzadreams.com/dk/

Genes or Environment - What Causes Eating Disorders?

Research has determined that eating disorders are caused by a confluence of factors. No one single factor is enough to cause someone to develop an eating disorder, but certain factors set the stage for a person to be vulnerable to developing an eating disorder. When it comes to eating disorders, the age-old question of “nature v. nurture” is answered simply: it’s a mixture of both. 

In the Fall 2005 issue of “Focus,” a journal of the American Psychiatric Association, in an article titled, “Eating Disorders,” several top researchers and clinicians in the field (Joel Yager, M.D., Michael J. Devlin, M.D.,  Katherine A. Helmi, M.D., David B. Herzog, M.D., James E. Mitchell, M.D., Pauline S. Powers, M.D.  and Kathryn J. Zerbe, M.D.) state that, “In recent decades, researchers have increasingly appreciated the multifaceted contributions to the etiology and pathogenesis of eating disorders, including genetic, familial, developmental, and psychosocial influences.” 

Are eating disorders biologically based? In the sense that certain genetic traits must be present in order to render a person vulnerable to developing an eating disorder, yes. In the sense that, if the various genetic markers are present then the person in question will develop an eating disorder regardless of any other factor, no. Recent research on the genetic factors that contribute to the formation of an eating disorder reveals that, while genes are indeed a factor, they alone cannot cause an eating disorder. Cynthia Bulik, PhD., Director of the UNC Eating Disorders Program at the University of North Carolina at Chapel Hill School of Medicine is often quoted as saying of eating disorders that, “Genetics loads the gun, but environment pulls the trigger.” In other words, the genetic vulnerabilities must be there, but an eating disorder won’t emerge unless the right environmental conditions are present. Click here to see Dr. Bulik discuss this. 

In an article co-written by Dr. Bulik and Suzanne E. Mazzeo, PhD., Associate Professor of Counseling Psychology at Virginia Commonwealth University, in the Journal Child and Adolescent Psychiatric Clinics of North America, Volume 18, Issue 1, January 2009: “Environmental and Genetic Risk Factors: for Eating Disorders: What Every Clinician Needs to Know,” Mazzeo and Bulik refer to  gene-environment, or G-E, correlation, and posit that, “Ultimately, the elucidation of causal models for eating disorders will no doubt include various types of genetic and environmental interplay…...Clinicians and researchers must become educated in the nuances of GxE interplay and avoid perpetuating purely environmental or purely genetic conceptualizations of eating disorder etiology.”

This speaks to the role of the family system, as one of several environmental factors, in potentially providing an eating-disorder-friendly habitat, so to speak, for a child whose genetic makeup renders her vulnerable to developing an eating disorder. Mazzeo and Bulik note that,” For decades, parenting styles have been unrightfully blamed for causing eating disorders. Considerable care must be taken when discussing GxE interplay not to convey the message that somehow parenting is to blame for these pernicious illnesses. Conversely, a purely genetic explanation should not be taken to mean that parents need not examine their parenting style and the influence it might have on children.” They state that not only is parenting style influenced by the parents’ genes, but that also, the genetically influenced constitution of the children affects the way that a given child reacts to the parenting. For example, a child with the genetic constitution for developing an eating disorder might be much more aware of physical appearance than her differently-gened sibling, and ask for more feedback about her appearance, thus generating more comments about her appearance from her parents (and others) than her sibling. 

So the interplay of genetics and environment is complex, within each environmental factor, in this case, parenting. Other environmental factors include life events and media that glorify a thin body shape.  Research shows a relationship between trauma and eating disorders. In an article in “Eating Disorders: The Journal of Treatment and Prevention,” July 2007, titled “Assessment of Trauma Symptoms in eating Disordered Populations,” authors John Briere and Catherine Scott write: “Research suggests that individuals with eating disorders (EDs) are relatively likely to have been abused or neglected as children, or to have been victimized in adolescence or adulthood. These experiences, in turn, are often associated with a range of psychological symptoms, as well as, in some cases, a more severe or complex ED presentation.” 

It’s important to recognize that difficult life events, from a major move to physical or sexual abuse (which have been shown to be risk factors for bulimia), are experienced differently by a person who tolerates distress poorly, and a person who tolerates distress well. The ability to tolerate distress is, in part, genetically influenced, but also has to do with how distress tolerance was modeled and taught in the person’s family. 

With regard to cultural notions about ideal body size and shape, everyone is exposed to media images of ultra-thin ideals, but not everyone develops an eating disorder. These things will affect someone with the “right” genetic markers differently from someone who does not have them. But how parents and other elder family members handle the media imagery, and whether they share the idealization of ultra-thin bodies, also influences the child.

Suffice it to say, eating disorders are complex creatures, and their causes are equally complex. No one factor accounts for the formation of an eating disorder. Eating disorders are best understood via a biopsychosocial model, which takes into account genetics, our personal selves (thoughts, feelings and behaviors) and the familial and social contexts in which we grow up and live. When it comes to treating disordered eating, the latter two must be addressed. We can’t change our genetic makeup, but we can change the way we think, the way we manage our emotions, the way we behave, and, in adulthood, the circumstances in which we live.  And we can avail ourselves of therapies that focus on healing the damage done by earlier experiences.~ Overview provided by Deborah Klinger, MA, LMFT, http://www.pizzadreams.com/dk/

How Psychotherapy Can Help with Eating & Food Issues

Eating and food issues, while not caused by the standards of a given culture, can “use” a cultural norm as a backdrop against which to camouflage “themselves.” For example, in her book, Fasting Girls: The History of Anorexia Nervosa, author Joan Jacobs Brumberg describes how in medieval times, anorexia nervosa was misperceived as evidence of attainment of a higher spiritual level, in the form of young women who no longer needed the carnal sustenance of food. Today’s climate, with emphasis for younger women on being “hot,” and for all women (and to an increasing extent, men) a focus on watching one’s weight, BMI, caloric/fat gram/carb intake, a disordered relationship with food/exercise/body can masquerade as “healthy.”

Behind these attitudes lurks a belief that not only is fat bad and thin good, fat and thin are statements about a person’s character- if one is fat, she IS bad/unlovable/unwantable. If one is thin, she is good/lovable/wantable—or at least is passing for those things. Eating disorders sufferers who starve themselves, induce vomiting after eating, exercise when it is not medically safe or out of a belief that they are in danger of being fat or flabby, are governed by a tremendous fear of becoming fat, and a belief that they are fundamentally lazy slobs. Those who feel compelled to overeat or binge eat believe their behavior with food and the size, shape and weight of their bodies are proof of their worthlessness. Thus, food and eating issues are expressions of problems with one’s sense of self and self-worth.

Eating and food issues are also indicators of struggles with anxiety and poor ability to cope with emotional affect, in which the body becomes the battleground upon which these conflicts are enacted. (A 2004 study by the University of Pittsburgh showed that a high percentage of individual with eating disorders have a co-occuring anxiety disorder, often present prior to the onset of the eating disorder.) An individual’s body becomes a concrete, visible entity that she can focus on and attempt to achieve mastery over. Such mastery, whether in the form of sticking to a diet, eating less than is appropriate for one’s health, running 5 miles, or vomiting after eating (with or without bingeing), serves to reduce anxiety and give an illusion of power or validity in the presence of a tenuous sense of self-worth. And because food is so fundamental a survival need, a conflicted relationship with food is an expression of conflict around one’s right to want and need.

Recovery from disordered eating is a long and arduous process. Many clients give up because of lack of motivation and energy to commit to the work involved. It is important to recognize that recovery involves not simply attaining 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 reverence for one’s self.

What Type of Therapy is Best For Treating Eating & Food Issues

Many different types of psychotherapy are used to treat eating disorders. Attention is increasingly paid to “evidence-based practices,” that is, treatment modalities that have been proven by research to be effective. While the importance of proven effect is understandable, the use of therapeutic modalities that have not yet been the subject of research for the treatment of eating disorders should not be ruled out. The Academy of Eating Disorders says this is their online statement about eating disorders treatment:

“There are several different types of outpatient psychotherapies with demonstrated effectiveness in patients with eating disorders. These include cognitive-behavioral therapy, interpersonal psychotherapy, family therapy, and behavioral therapy. Some of these therapies may be relatively short-term (i.e., four-months), but other psychotherapies may last years.

It is very difficult to predict who will respond to short-term treatments versus longer term treatments. Other therapies which some clinicians and patients have found to be useful include feminist therapies, psychodynamic psychotherapies and various types of group therapy.” (http://www.aedweb.org/Treatment.htm).

The phrase, “other therapies which some clinicians and patients have found to be useful” deserves underscoring, as it speaks to the experience of healing that therapists and clients share. Cognitive Behavioral Therapy, a long-standing and well-researched method, is often used to treat eating disorders. The Maudesly Family-Based Approach has been demonstrated to be very effective for children and adolescents suffering from anorexia or bulimia who live with their parents (and parental involvement in treatment is a must for this population). Dialectical Behavioral Therapy (DBT) has also been the subject of research that demonstrates its effectiveness in the treatment of eating disorders. 

But many clinicians see these methods as only some of the tools that help disordered eaters recover. “The Anorexia Workbook,” by Michelle Heffner, M.A., and Georg Eifert,  Ph.D., features Acceptance and Commitment Therapy (ACT). Castlewood Treatment Center, a residential eating disorders treatment center, not only utilizes the Internal Family Systems (IFS) model of psychotherapy, but has brought on the founder of IFS, Richard Schwartz, Ph.D., as part of the treatment staff. Some residential treatment centers, such as Sierra Tucson, use a 12-Step approach, incorporating the philosophy originated in Alcoholics Anonymous to treat eating disorders through the lenses of addictions and emphasizing a spiritual component. Most residential treatment centers for eating disorders incorporate complementary modalities such as yoga, art therapy and equine therapy into their programs. Psychotherapists who treat eating disorders in outpatient practice usually recognize the importance of adjunctive therapies and utilize resources such as DBT skills groups, group therapy, expressive arts therapies, yoga therapy, specialty yoga classes and self-help programs such as Eating Disorders Anonymous. It takes a village to treat an eating disorder.~ Overview provided by Deborah Klinger, MA, LMFT, http://www.pizzadreams.com/dk/

How Eating & Food Issues are Medically Treated

Anorexia and bulimia nervosa are physically dangerous disorders. Anorexia has the highest premature fatality rate of any mental disorder (Sullivan, 1995). Because the disorder involves self-induced starvation, an anorexic can die of malnutrition, but is also at risk for refeeding syndrome; an electrolyte imbalance caused by a sudden increase in nutrient intake than can lead to cardiac or respiratory arrest.

Bulimia nervosa carries a great deal of medical risk as well: constant vomiting can not only cause electrolyte imbalances, creating possibility of damage to the heart, but puts a bulimic in danger of esophageal rupture.

Obesity burdens a body’s system and puts one at risk for related health problems such as type II diabetes.

Research has shown that medication targeting the serotonin system can be helpful with impulse control as well as mood, and thus useful in treating binge eating and bulimia as well as depression and anxiety that are so often concomitant with disordered eating. But for patients who are undernourished, food is the most important medicine. 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.

When outpatient therapy proves inadequate, a higher level of care is necessary. They range in intensity from intensive outpatient (IOP), in which a patient attends a treatment center for several hours a day, partial hospitalization, in which a patient attends a hospital program during the day but not on evenings or weekends, residential treatment, in which a patient lives at a non-hospital treatment center for a month or longer, and inpatient treatment, in which a patient lives in a hospital eating disorders program. There are discrete level-of-care guidelines delineating the criteria for a patient’s status at each level. ~ Overview provided by Deborah Klinger, MA, LMFT, http://www.pizzadreams.com/dk/

DSM Criteria for Eating Disorders

The DSM IV criteria for eating disorders are as follows:

Anorexia Nervosa

• Refusal to maintain body weight at or above a minimally normal weight for age and height: Weight loss leading to maintenance of body weight <85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected.
• Intense fear of gaining weight or becoming fat, even though under weight.
• Disturbance in the way one's body weight or shape are experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight.
• Amenorrhea (at least three consecutive cycles) in postmenarchal girls and women. Amenorrhea is defined as periods occurring only following hormone (e.g., estrogen) administration.

Type of Anorexia Nervosa

• Restricting type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (self-induced vomiting or misuse of laxatives, diuretics, or enemas).
• Binge-eating–purging type: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Bulimia Nervosa

• Recurrent episodes of binge eating characterized by both:

1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
2. A sense of lack of control over eating during the episode, defined by a feeling that one cannot stop eating or control what or how much one is eating

• Recurrent inappropriate compensatory behavior to prevent weight gain

1. Self-induced vomiting
2. Misuse of laxatives, diuretics, enemas, or other medications
3. Fasting
4. Excessive exercise

• The binge eating and inappropriate compensatory behavior both occur, on average, at least twice a week for 3 months.
• Self evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.

Type of Bulimia Nervosa

• Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
• Nonpurging type: During the current episode of bulimia nervosa, the person has used inappropriate compensatory behavior but has not regularly engaged in self-induced vomiting or misused laxatives, diuretics, or enemas.

Eating Disorders Not Otherwise Specified (ED NOS). Eating disorder not otherwise specified includes disorders of eating that do not meet the criteria for any specific eating disorder.

1. For female patients, all of the criteria for anorexia nervosa are met except that the patient has regular menses.
2. All of the criteria for anorexia nervosa are met except that, despite significant weight loss, the patient's current weight is in the normal range.
3. All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur less than twice a week or for less than 3 months.
4. The patient has normal body weight and regularly uses inappropriate compensatory behavior after eating small amounts of food (e.g., self-induced vomiting after consuming two cookies).
5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
Binge-eating disorder is recurrent episodes of binge eating in the absence if regular inappropriate compensatory behavior characteristic of bulimia nervosa.

(Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text rev. Washington, DC, American Psychiatric Association, 2000)

"Perfectionist" Personality Type Leads to Anorexia - Case Example

Cathy, a 25-year-old 2nd-year med student, came to therapy because some fellow students expressed their concerns about Cathy’s extreme weight loss and increasing lack of participation in social events. Cathy maintains that she is fine, that she is simply stressed out about school, and puts grades ahead of socializing. At 5’4” and 96 lbs, she has a BMI of 16.5. She states she is menstruating regularly, though very lightly, and has been on birth control pills for the last 4 years. Further questioning revealed that Cathy was teased for being chubby in middle school and for a period of time in middle and high school, engaged in inducing vomiting after meals. Since the she has an intense fear of becoming “the fat kid that no one likes,” and said that she had been maintaining her weight around 110 lbs until the beginning of this school year, when the pressures of school made her, as she puts it, “aware of how important it is to be the best,” including being the thinnest, and she began cutting back on her food portions, eliminating fats from her diet, and avoiding social situations in which food is involved, because “I don’t know what’s in it.” Cathy’s therapist referred her to a physician for medical monitoring, and a dietician for help devising an appropriate meal plan. Cathy’s therapist began by first separating anorexia from Cathy, helping Cathy view anorexia as an unwelcome guest who had take over Cathy’s brain. She helped Cathy challenge Cathy’s distorted, anorexia-driven thinking about Cathy’s body’s needs for nutrients and energy. As Cathy’s eating improved and her brain became well-nourished enough to participate more fully in the therapeutic process, Cathy became aware that she has tremendous fear of being less than perfect, stemming in part from her parents’ focus on her academic achievements in tandem with their lack of focus on her inner emotional experiences. When her parents divorced when Cathy was in 5th grade, Cathy saw that her parents seemed happier when she did well in school, and she wanted to help them feel happy. She wanted also to make sure that wasn’t a burden or an unhappy reminder of their failed marriage. She had learned to ignore her own emotional needs, and this was reflected in her denying her physical need for food. As she re-connected to her feelings, her therapist guided her to manage painful emotions rather than starving them away, and she found that she was increasingly less fearful of becoming obese and more comfortable in her body. Cathy’s therapist referred her to a psychiatrist who prescribed medication for the obsessive-compulsive anxiety related to her perfectionism. She has learned to recognize and challenge the “voice” of anorexia, and affirm her right to feel her feelings and her physical hunger, and need help and support from others as well as food.

Stress and Self-Hatred Causes Weight Gain - Case Example

Yvonne, 38, is an elementary school teacher who has been overweight since childhood. She has been on hundreds of diets, losing weight but them regaining it, often gaining more weight than she lost initially. She berates herself for being “a fat pig,” and feels ashamed of her lack of willpower. She is divorced, and her ex-husband used to make nasty remarks about her weight, to which she reacted by retreating to her den in tears and waiting until he went to bed so she could sneak into the kitchen and soothe herself with ice cream and cookies. After such an episode, she would mentally flagellate herself for her shameful behavior, and vow to be strong and disciplined from then on. She came to therapy because she felt defeated by her lack of ability to follow through on her promises to herself, and wondered if she had a problem with emotional eating. She was concerned that the idea that she was, perhaps, an emotional eater, was just an excuse for her weakness as a human being. Her therapist explained disordered eating, and the relationship between painful emotional states and the misuse of food as an antidote. She gave Yvonne tools for tuning into her body’s hunger and satiety signals, and using those as a guide to when her body needed food, rather than following a weight-loss plan. At the same time, she taught Yvonne to use urges to overeat as signals that she was experiencing something emotionally that she needed to attend to. Yvonne learned to value herself and her needs, and created a “toolbox” of self-care skills she could use when feeling bad or wanting to overeat. She explored her family dynamics, and recognized the effects of her father’s alcoholism on her family and specifically on her relationship with food and her body—she had unknowingly learned from her father to stuff painful feelings down, and began 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 her 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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