Eating disorders can be as much of a social issue as they are psychological, particularly in the ways our society has normalized disordered eating and an obsession with thinness. This makes this disorder easier to hide and more complex in some ways than other mental health conditions. In a meeting with Ruth Flynn of the Renfrew Center — the oldest freestanding eating disorder clinic in the nation — the Rivia Mind team was fortunate to learn more about the complexities of eating disorders and how to help patients who need a higher level of care.
Developing Factors of Eating Disorders
Eating disorders often have a variety of developing factors, from the social to the psychological. Even biological factors can sometimes play a role. Let’s dive into the different factors that can lead to the development of eating disorders.
Social Factors
Our culture has valued thinness for decades, and this has only been intensified with the rise of social media. There is an obsession with diets and weight loss, with pressure to try new fad diets at seemingly every corner.
Fat oppression also plays a significant role. People with larger bodies struggle with receiving adequate medical care, finding employment, and in social settings like dating compared to their thinner counterparts. The messages our society sends out make it easy to feel as though the only way they can be taken seriously or seen as attractive is by losing weight.
Psychological
Mental health can also play a role. If you struggle with self-esteem, that low self-esteem can be directed at your weight. Co-occurring conditions like anxiety, OCD, and PTSD can also add to the development of eating disorders.
For some with eating disorders, it’s less a matter of needing to be thin and more a matter of feeling a sense of control over their lives or avoiding uncomfortable emotions. This is especially true for those with a history of trauma.
Biological
Especially for eating disorder patients in a higher level of care, genetics may also impact the development of eating disorders. A 2019 study across 17 countries found that many of the genetic basis for anorexia nervosa overlapped with OCD, depression, anxiety, and schizophrenia — offering evidence that genes can in fact put someone at higher risk of developing an eating disorder.1
Many patients with eating disorders who need a higher level of care also have a parent or sibling who has or had an eating disorder. This could be biological or it could be a matter of environment. If a child grows up surrounded by examples of unhealthy relationships with eating, they may in turn mimic those relationships.
Comorbidities and Intersectionality
Eating disorders do not exist in a vacuum. Often, they are impacted by other co-occurring conditions or comorbidities, including:
- Depression
- Anxiety
- Borderline personality disorder (BPD)
- Post-traumatic stress disorder (PTSD)
- Obsessive compulsive disorder (OCD)
- Substance use
One study that looked at over 2,400 patients hospitalized for eating disorders found that a staggering 94% of patients had co-occurring conditions.2 This included:
- 50-80% with anxiety
- 30-50% with depression
- Nearly 50% with substance use
- 20% with OCD
Those with substance use needed to go through treatment for the substance use before they could move on to treating the eating disorder. In other cases, however, it was important to treat the eating disorder first. Doing so sometimes allowed patients to be more aware of other mental health issues they were facing, once they were no longer using their eating disorders to avoid their emotions.
In addition to comorbidities, cultural identities can also impact the way that eating disorders develop and present themselves. This is why good eating disorder specialists should consider intersectionalities of:
- Race and ethnicity
- Age group
- Socio-economic status
- LGBTQ+
- Gender
- Body type or size
Why Eating Disorders Are Hard to Catch
Eating disorders are not as easy to see as other illnesses. Many with eating disorders have learned to hide or mask their eating disorders so as not to arouse suspicion. They can also be easy to hide due to societal misconceptions and normalizations.
The image we’re often presented of eating disorders is one of thin, white teenage girls. But eating disorders can occur with any body type. In fact, those with larger bodies who reach out for help are often discounted as having eating disorders and may struggle to maintain treatment. Society’s obsession with fad diets and thinness can also make disordered eating habits look normal.
The Disordered Eating Continuum
Because the development of eating disorders can be so subtle, it’s important to consider the disordered eating continuum, from what a healthy relationship with eating looks like to eating disorders.
Wellness
Those with healthy relationships to eating have mostly positive or at least neutral feelings about their body type and size. They do not see food in terms of “good” or “bad.” They engage in moderate exercise, less due to a fixation on thinness and more for overall health.
Preoccupation
If someone has a preoccupation with their body and eating, they may not outright hate their appearance; rather, there might be a few aspects of their appearance that they tend to fixate on. They may be consistently looking for ways to lose “a few pounds.” Frequent thoughts or mentions about eating and food occur. In preoccupation, it can be common to feel guilty about eating certain foods and to promise to “make up for it.”
Distress
Those distressed with their body image or eating habits find that thinking about food and eating often interferes with their daily activities. They develop rigid eating patterns and fixate on changing their body or compensating for eating. These might be people who frequently try out new fad diets.
Eating Disorders
The next step is eating disorders: binge eating, starving, or some unstable combination between the two. It’s important to note that exercise can also fall into eating disorders, as a way to purge or “make up for” an eating binge.
Types of Eating Disorders
Diagnoses often change and shift within eating disorders. For instance, anorexia most often comes up during adolescence. But because anorexia is not sustainable for a long period of time, it might shift towards bulimia, binge eating, or “atypical anorexia,” swinging between binging and starving.
There are common indicators for each type of eating disorder. But it is important to keep in mind that eating disorders are often in flux and every case is different.
Anorexia Nervosa
Anorexia nervosa is primarily characterized by strict reduction of food intake. Some indicators include:
- Refusal to eat certain foods or food groups
- Rigid focus on weight leading to an impact on mood
- Development of food rituals
- Body checking
- Excessive weighing
Bulimia
On the other hand, someone with bulimia will often eat their full and even binge eat, only to then force themselves to purge — through exercise, laxatives, or through induced vomiting. Indicators include:
- Disappearance of large quantities of food
- Dramatic weight fluctuations
- Leaving for the bathroom immediately after meals
- The presence of wrappers, laxatives, or diuretics
Binge Eating
Binge eating has some overlaps with bulimia in terms of indicators, such as disappearances of large quantities of foods. Binge eating, however, does not have the subsequent element of purging. Those who struggle with binge eating may do so as a form of avoidance from their emotions. These binges may be followed by feelings of intense shame, which then exacerbates the need to binge.
Some indicators of binge eating are:
- Hiding food
- Eating alone
- Rapid eating
- Difficulty identifying hunger and fullness cues
- Planning binges in advance
Avoidant Restrictive Food Intake Disorder (ARFID)
ARFID differs from other eating disorders in that it is not typically based on body image. Rather it is characterized by food restriction due to an intense avoidance of certain foods or food groups. This can be based on texture or taste. Picture picky eating in its most extreme form. ARFID is common with those who have OCD or autism spectrum disorder and may have particular sensory issues.
Indicators of those with ARFID include:
- Constipation, abdominal pain, or cold intolerance
- Lethargy or excess energy
- Consistent, vague gastrointestinal pain to avoid eating
- Fears of choking or vomiting
- Lack of appetite or interest in foods
- Increasingly narrow range of preferred foods, such as only eating certain textures
Other Specified Eating or Feeding Disorders (OSFED)
OSFED is something of an umbrella diagnosis for combinations of the other eating disorders. It often occurs in the early adult to midlife range, and it can be easier to hide with subtler symptoms. These include:
- Food rituals
- Frequent new practices with food
- Discomfort eating around others
- Disappearing shortly after eating
Evidence-Based Treatment for Eating Disorders
Evidence shows that eating disorders are often issues of emotional dysregulation. Like many mental health conditions, they can be born of a drive to avoid, suppress, or control negative emotions rather than experiencing them. Thus it’s important to help those with eating disorders sit with their feelings and re-evaluate maladaptive cognitive appraisals. By sitting with feelings without judgment or shame, patients will reduce their need to return to harmful avoidance tactics — such as eating disorder behaviors.
Flynn described Renfrew’s approach as: “We don’t help you feel better, we help you get better at feeling.”3 They utilize emotional exposures to promote tolerance of uncomfortable emotions. With this, the patient can learn psychological flexibility and emotional regulation.
Emotional Exposures
Emotions are signals from the body, letting you know when something is wrong. Negative reactions to emotions such as attempts to avoid or control them maintain symptoms of eating disorders. In a good eating disorder rehabilitation, patients learn how to disrupt their pattern of avoidance and sit with their emotions.
Through emotional exposures in a structured environment, patients not only practice emotional regulation but inhibitory learning — essentially learning not to act on their impulses. Clinicians will provide structure and set expectations for the exposure. There is also a variety of stimuli and processes to be used, but repetition is key. With repetition, these exposures become easier and emotions become less intense.
Types of exposures include:
- Naturalistic – preparing for exposures that are likely to happen in real life, such as going to the grocery store and seeing food or going to visit family
- Imaginal – sitting and discussing a potential trigger situation and how to react to it
- In Vivo – planning out situations in which the patient can expose themselves to something triggering in small doses
- Interoceptive – things like breathwork, bilateral tapping, and other ways to ground yourself in situations of distress
Higher Level of Care for Eating Disorders
Higher level of care (HLOC) refers to more intensive treatments for patients who need further support in treating their eating disorders. This can include:
- Inpatient hospitalization
- Residential facilities with others treating their eating disorders
- Partial hospitalization treatment (PHP) or day treatment
- Intensive outpatient
When To Consider HLOC
So when should you consider a higher level of care for your eating disorders? It’s different for everyone, but there are a few key indicators:
- When symptom usage such as food restriction, binging, or purging goes up
- When you experience rapid weight fluctuations over a short period of time
- When there is a concern for safety or self-harm
Care providers may also request labs that could indicate whether or not the case merits HLOC.
Having the Talk
Your clinician may recommend you try a higher level of care such as an outpatient program or residential setting. This may be a difficult conversation but it’s important to know that there is no judgment of you as a person. While HLOC may seem disruptive to your life, consider that your life is likely already “on hold” due to your eating disorder symptoms. HLOC programs are a way to help you return to your life.
You and your clinician will first identify your supports in your life and develop a treatment team including:
- Dietician
- Possible family therapist
- Individual therapist
- Primary care physician
- Psychiatrist
If possible, you should try to work with certified eating disorder specialists. This will be hard work. Know that you have support and skills to tackle that work, and that it will help you reach your goals in the long run.
Rivia Mind offers a number of therapists and psychiatrists who specialize in eating disorders, and we’re here to help you. Contact us today to learn more or to schedule a free 15-minute consultation.
References:
- H. J. Watson et al., “Genome-wide association study identifies eight risk loci and implicates metabo-psychiatric origins for anorexia nervosa,” Nature Genet., vol. 51, no. 8, pp. 1207–1214, online Jul. 15, 2019, doi: 10.1038/s41588-019-0439-2.
- When Eating Disorders Combine With Other Mental Health Issues — NAMI Illinois
- The Renfrew Unified Treatment Model For Eating Disorders and Comorbidity: an Adaptation of the Unified Protocol – The Renfrew Center
