What Makes Eating Disorders so Different

Every eating disorder starts with a diet. Most diets peter out when the person gets too hungry, but sometimes it leads to a different kind of hunger, one that triggers a cascade of largely physical reactions that can result in an eating disorder. But the hunger can be of many kinds. Perhaps it is a type of high, emotional but also psychological, from feeling as if one has mastered food. Or maybe it is an all-consuming hunger that makes one want to eat and eat and eat. Maybe the hunger becomes irrelevant because it feels so good to lose weight. For these people, once the hunger takes over, there is no turning back.

What other mental disorder starts with a choice, a seemingly innocuous choice, that spirals out of control? Maybe it even starts with a thought: I want to lose weight. Moreover, what adolescent girl--and, more often these days, boy--doesn't try dieting at some point? Does that mean everyone is exposed to the trigger for an eating disorder? Does that mean anyone can get an eating disorder?

It's hard to imagine having this discussion about any other mental disorder. Psychiatrists talk about a prodrome, a cluster of symptoms which appear to herald the onset of a psychiatric illness. The prodrome for an eating disorder could just be adolescence. Our culture extols the ability to remain thin and eat little in a world of abundance of all kinds of food. No one is more vulnerable to cultural mores than teenagers. When everyone is exposed to an environment ripe for developing an eating disorder, it begins to feel like everyone who is predisposed to get one will.

Although the mental health world has adapted over the last century to different conceptual frameworks for illness, psychiatric symptoms have remained fairly consistent: anxiety, depression, delusions, hallucinations. They have all been documented under one name or another and can be traced through the evolution of psychiatry, but eating disorders only entered the mental health lexicon in the last few decades. The almost meteoric rise from newly described illness to national obsession occurred within a generation, or perhaps two. The discipline is still trying to catch up on all levels: diagnosis, treatment programs and even basic treatment success.

Sometimes, I even wonder if eating disorders are really mental disorders. Maybe they belong to a whole different class of illness, the result of a broader national miscalculation which has exploited a cornerstone of human survival. Our food supply has been transformed in recent decades. Agribusiness and processed food, primarily using corn and soy, has provided our society with an abundance of food for the first time in the history of humans. The US makes almost twice as much food as the people living here need. We have gone from a people seeking enough food to survive to a world with, in theory, more than enough for everyone. Food changed from an urgent necessity to a continual choice. We can find anything we want to eat at any time. This means survival on a global scale but at what price? Our hunger was adapted to a world with a more limited supply of food, and we are ill-equipped to cope with such a plentiful environment. Hunger was a visceral, physical signal to the body to get food. Now many people experience hunger infrequently. Instead we are pushing new boundaries: either how much we can eat, what is our capacity, or how much can we withstand hunger with food all around us. There never has been the need before to adapt to times of plenty. Like it or not, this is our grand experiment.

Every person born today lives in this new world. Each person and each child has to learn how to balance hunger and fullness in the constant presence of food. No one knows how an entire country will handle hunger when faced with more than enough food, and not just food but all types of tasty and tempting food. This is food an entire industry spends enormous amounts of time and money developing to appeal to our most basic senses. The industry has worked hard to find food that will override any rational desire to stop eating. The result has been disastrous: rising rates of obesity, a steep increase in eating disorders, ineffective government iniatives to promote nutrition, and the exploitative food industry.

Re-reading this post, I realize there is a lot more to discuss in each point. The next few posts will explicate these thoughts in more detail. If these are the current conditions which exposed our evolutionary weaknesses to food and hunger, who among us ends up with an eating disorder? What makes those of us susceptible? Look for the next post.

Food Journals

The food journal is a simple, effective but underused tool in eating disorder treatment. Both clinicians and patients balk at incorporating the journal into treatment. Therapists consider it too simplistic to be effective. They fear the therapy will not address the patient's underlying emotions or believe only nutritionists should discuss food. Patients are too ashamed to discuss specific food choices or find the daily journal too cumbersome. When both therapist and patient really sign on for the food journal, the treatment feels like it has taken a shortcut to trust, honesty and progress. By addressing food from the start, the journal can be the catalyst for real life changes.

The food journal itself includes the date and time of eating, specific foods and amount eaten, whether the meal is overeating or a binge and the thoughts and feelings at that time. If possible, each entry should be written at the time of the meal. The format of the journal can be a chart, narrative, or daily emails, but I am always surprised by creative ways a patient will write her journal. The best option is the one that works for the patient. The journal can be in any form as long as it gets done. In the session, the therapist and patient review the journal and learn how to work together to understand the eating disorder, a process based on Cognitive Behavioral Therapy or CBT.

The essential component of CBT--a mainstay for eating disorder treatment--is the food journal. This approach involves identifying patterns between eating disorder thoughts and behaviors, increasing awareness of these patterns and devising methods to change them. The biggest problem with CBT is commitment to the journal itself. While this type of therapy can be very effective, there is little guidance on how to ensure the patient completes the journal.  Often, what is missing is a sense of urgency. What is the purpose of recording her food daily? Why should she bother? She needs to know and truly understand that the journal can be the bridge to hope and then recovery by addressing the most insidious and powerful part of any eating disorder, secrecy.

Because patients feel intense shame about themselves and the symptoms, hiding the disorder feels like the only option. Each and every subsequent slip into the symptoms induces more guilt. Each time, she says, will be the last. Each time only reinforces the need to remain hidden until the eating disorder goes away. This vicious cycle makes her feel more and more isolated from family and friends and increasingly hopeless about her life. The therapist needs to break through the cycle to help her believe she is capable of eating in a different way and becoming free from the overwhelming hopelessness.

How can a food journal change anything? I hear that question every time I mention it. First, the journal establishes a consistent, daily connection between therapist and patient. Moreover, the communication in therapy starts with the biggest secret in her life--things she frequently has never told anyone before--behaviors around food. This is a huge leap for the patient and a huge responsibility for the therapist, but these steps are necessary because eating disorder treatment needs to tackle the secrets directly. The patient cannot be alone anymore.

The journal means honesty for the patient with her therapist and with herself. This can be a remarkably liberating experience after years of feeling captive to the cycle of thoughts and behaviors. Instead of deluding herself that each day will be her last eating disordered day, she has a partner to help demystify and change her relationship with food. The sense of collaboration transforms the immediate experience in therapy for the patient. Regular talk therapy can feel like an inquisition which only reinforces her sense that she is broken. The journal can change that. It is the physical object the team--patient and therapist--can look at and learn from together. The therapy is not judgmental but objective, and the goal of each session is to learn how to do the work of treatment together? It means the patient has the answers too; she is no longer powerless. So many patients avoid treatment because the shame is overwhelming, but here the shame is secondary to the collaboration. The shame is transformed into trust and a renewed hope for the future.

This entire post reveals a fundamental difference between eating disorders and other mental disorders. No other disorder becomes a way of life so powerful, so shameful and so secretive that it can consume a patient entirely. No other disorder is highly praised by society. No other disorder arose from nowhere less than forty years ago. The next post will begin to consider these differences and the bigger question: why is this disorder different from all other mental disorders?

Diagnosis

The first eating disorder diagnosis, Anorexia Nervosa, was described in 1973. In the DSM-IV-TR, there are only two accepted diagnoses--anorexia and bulimia--and a grab bag classification called eating disorder not-otherwise-specified (EDNOS) for everything else. There is a lag between relevant diagnoses and the steep rise in the incidence of eating disorders and eating disordered syndromes, and this lag makes the current system essentially irrelevant for treatment. Many other diagnoses have been suggested: binge eating disorder, night eating syndrome, orthorexia, purging disorder and compulsive overeating. The psychiatric community has had difficulty codifying these symptoms into disorders largely because they are a social phenomenon or perhaps even a lifestyle choice. Due to multiple individual and societal pressures, manipulating food has become a way of life. As is evident from my previous posts, I believe these symptoms only lead to isolation and misery, but the purpose of this current post is to present an eating disorder classification system.

When it comes to treatment, only two variables really matter: the length of the illness before effective treatment and the most prominent symptom of the disorder. If effective treatment starts within the first five years, then the goals are to stabilize eating, normalize weight and return the patient to her pre-eating disorder way of life. At this point, she will more easily fall back into her natural eating patterns and her natural social patterns. Treatment is likely to be more successful and more uniform no matter the diagnosis. Her eating disorder will only be a coping strategy, not yet a lifestyle. She will be able to join her peer group relatively quickly in terms of education, friendships and relationships. Even though a significant minority of these patients will become chronic, expecting success can turn around even the most gravely ill patient early in the course of the disorder.

For people with chronic eating disorders, usually five years or longer, recovery for the patient feels more like introducing a new way of living. The eating disorder has become a buffer between herself and the world. What appears to the outsider to be liberation from the symptoms can feel oppressive, exposing and terrifying to the patient. After a lengthy illness, she can rarely fall back into pre-eating disorder living and feels as if she has fallen too far behind her peer group to ever catch up. Sadly, the benefits of remaining sick often look more appealing.

The core of successful treatment with chronic patients is personal connection. If she can break down the barrier of the eating disorder and connect in any relationship--in her life or in therapy--she can start to realize and want what she is missing. That desire and motivation is crucial to have any chance at success. The therapy relationship itself is often the critical tool that can break the hold of the disorder. The means of finding connection depends not on
diagnosis but on the primary symptom of the disorder: starving, binging and purging (vomiting, laxatives, diuretics, over-exercising etc.) or overeating.

People with chronic eating disorders almost always fall into the diagnosis EDNOS. Few people sick longer than five years are able to sustain the same symptoms. As her body adapts to the disorder, she needs to find new symptoms to survive, ie binging to compensate for long-term starvation or laxatives when she can no longer vomit. These adaptations don't change the primary symptom, and the psychological key to recovery lies in that core symptom.

People whose prominent symptom is starvation have tied up their entire identity in the ability to control hunger and remain thin. Society has lavished her with praise. She has figured it out. Everyone is incredibly jealous. Even though starvation has always curtailed any other accomplishments, nothing surpasses the ability to master food. The attachment is so powerful, she will often overlook severe medical complications to continue to starve. The key to opening the door to treatment is to unlock her isolation and sadness. By connecting in a relationship, usually in therapy, she can remember how alone she is and how much she sacrifices to continue starving. The road to
treatment is long and arduous, but sometimes the desire to survive and truly live can gradually overcome the satisfaction of the illness.

For patients who primarily binge and purge, the disorder most closely resembles an addiction. The chemical high a patient experiences from binging and the release of purging only leads to a craving for more. Often, she feels powerless to experience eating any other way. The shame leads to the need to hide so even those closest to her may not suspect she has an eating disorder. The key to treatment begins with forging a new connection with herself. Exposure of all of her eating behaviors, binging included, in therapy in a detailed food journal is essential. As the patient gains some perspective on her disorder and begins to have success with normal meals, she loses both the cravings to binge and the internal sense of shame. Reconnecting both to herself and the people in her life provides essential feedback to continue down the road to recovery.

Overeating presents the newest, least studied and most controversial group of eating disorders. Food journals can certainly help distinguish overeating from binging and expose the level of shame associated with eating. Since these patients frequently have a lot of knowledge about nutrition, education is not a critical component of treatment. What makes these patients controversial is that the illness is a national phenomenon with political, industrial and psychological causes. For now I will focus on the psychological root. These patients have disconnected on a larger, societal level, and the treatment needs to bring them back to their own daily lives. In our community, people who are obese are often ignored or even invisible. They feel disempowered, desexualized and even dehumanized, almost as if they do not deserve the same rights as others. For many patients, this isolation provides security. The isolation limits the closeness in relationships and the expectations that might be imposed on them. The public scrutiny and judgment can reinforce their extremely low self-esteem. Food itself both provides both solace and punishment. These patients need to want to be part of the world again and to believe they deserve connection, respect and love. They are usually very aware of their isolation but do not believe it could be any different. It can be a lonely life, and the goal of treatment is to provide hope again, perhaps enough to reassess her relationship with food, her life and herself.

Food journals work their way into all categories of diagnosis independent of the duration of illness and primary eating disorder symptom. I will elaborate on the utility and benefit of journals in the next post.