A Functional Eating Disorder Defined

The concept of a functional eating disorder is a novel idea and even somewhat controversial. I realize in writing the last post, I did not explain this clearly enough and will do so here. 

Unless someone is very medically ill, a person can live and function to some degree with an eating disorder. The rigid structure of food, the persistent, intrusive thoughts and the significant limitations around food all have a significant impact on daily life. However, many of these people continue to have a career, friends and relationships. 

Chronic mental illnesses, especially ones with significant medical effects, typically interfere with these aspects of daily life much more. But people with eating disorders can compartmentalize their experience and suffering for extended periods of time. Moreover, the shame around the illness engenders secrecy and lying from the start so continuing to hide becomes second nature. And most other people just don't know what to look for and never recognize the telltale signs of the illness. 

Several aspects of the illness distinguish the person with a functional eating disorder.

The first is no hospitalizations which has two components. One is that the eating disorder symptoms have not caused the need for immediate medical attention or become too severe to successfully hide. The second is the person is lucky enough for her body to be resilient despite significant eating disorder symptoms. Two people can have essentially identical eating disorders, and one has been in treatment for years while the other has never had more than therapy. The first will not be functional and the second can be. 

The second component is that there are no significant cognitive or emotional effects of the illness. Some people find that their mind is not clear enough in the illness to complete school, hold down a job or maintain relationships while others do not have that difficulty. Again this discrepancy is based on biological differences and how each person brain reacts to starvation or binging. 

The last distinction is based on personal circumstance. Each person's life presents choices. If the choice to be functional is necessary, for example to escape family intrusion or to pursue personal goals, then that person will work to become functional despite the eating disorder symptoms. The effect is not recovery but simply a change in symptoms to maintain the cognitive ability m to hold down a job. 

The next post will compare the reality of someone with a functional and non-functional eating disorder and the third post will discuss more differences related to treatment and recovery. 


Recovery for the Person with a Functional Eating Disorder

People with less severe eating disorders, those never hospitalized or never in extended periods of treatment, often see themselves as very competent. They have a job and friends. They are independent and can take care of the necessary daily tasks of being an adult. People around them can rely on them to get things done. 

Upon seeking treatment, they express the same sentiment: "If I put my mind to it, I know I can take care of anything in my life, except for this."

I have heard this sentence, almost verbatim, countless times. I think it reflects a few important aspects of the process of living with an eating disorder and the process of recovery. 

First, this cohort of people with eating disorders is very functional and competent. Yet that aspect of their personality--which leads to successful lives in some ways--also fits comfortably into the eating disorder mindset: routine, clear rules about food and strict guidelines about weight as a marker of success. 

In other words, the part of themselves that works in all other areas of life utterly fails in recovery. In fact, that part strengthens the eating disorder. 

Recovery, even for less severe illnesses, still demands the same patience and process of relearning how to function in a completely different and paradoxical way around food. Willpower is not the cornerstone of recovery. Instead, patience and the ability to tolerate discomfort are. Those are something this cohort of people has been able to avoid through the years of their illness: any discomfort is quickly managed by eating disorder symptoms. 

People who have been less ill typically have more to lose. Although the eating disorder has limited parts of their lives, other parts have grown. The emotional struggle of recovery will make it hard to maintain those successful parts of their lives and may make it more challenging to stick with the discomfort. The reality of a life with limitations may seem more manageable in the moment. 

The key to this path of recovery is patience. Unlike people with more severe eating disorders, the process does not need to rush and immediately involve full treatment teams or residential centers. Patience allows for the time to understand and experience slower steps into recovery without sacrificing the healthy parts of someone's life.

Merging those parts of life with the benefits of recovery won't demand willpower but instead the willingness to learn how to tolerate painful emotions and discomfort around food. The incentive of a more full life and the inherent understanding and compassion of treatment can be enough to make full recovery possible.


Decisions about Treatment for End-Stage Eating Disorder Patients

The legal component of mental health treatment is complex and has no easy answers. That is compounded several times by the decisions around end-stage eating disorder care. 

The medical complications of eating disorders are often life threatening. At the most severe stage of illness, multiple organ compromise or failure is common, but successful treatment eludes even the most experienced physicians who aren't knowledgeable about these diseases. Consequently, end-of-life care is often very poor. 

Usually, at this stage of any illness, the patient has some awareness of the medical situation and can either express their wishes or has already stated them prior to becoming so compromised. That is often not the case with eating disorder patients. 

The severe state of malnutrition typically strengthens the eating disorder thought process, so many patients in danger of losing their lives cannot understand the severity of the situation. The eating disorder mindset becomes so ingrained at that stage of illness that any other way of thinking is incomprehensible, even when physicians clearly explain the dire consequences. Moreover, the family is usually aware of the fact that it has been years since the patient felt that any change was possible, if ever. 

Ethically, what is the family to decide and what can physicians do? Emergency medical intervention, even against the patient's wishes, can save her life in the short run. However, long-term forced treatment has proven time and again to be counterproductive and only intensifies the grip of the eating disorder. Families can acquire the legal power to make decisions for their adult child but to what end?

These questions highlight the challenges of how to help such a severely ill person with an eating disorder in a life-threatening stage of the illness. The answers are all unsatisfactory, and the outcomes all look bleak. 

If the family can work with the patient and doctors to all agree to life-saving medical care then that is a reasonable first step. But pressing further treatment only feels like a prison sentence to any patient. Accepting the limitations of current treatment options is a crucial part of medical decisions making once a patient has multiple organ compromise.

Kindness, compassion and understanding can have a significant impact even in the most dire cases. Sometimes, getting very ill, as awful as that is for the patient and family, can open the door to a new path of recovery.