The Role of Body Size in the Treatment of Restrictive Eating Disorders

An important new clinical question is how to diagnose and treat people with restrictive eating behaviors, psychological focus on weight loss and obsessive thoughts about food and weight in people who are not extremely underweight.

This week’s New York Times article discusses a new consideration in the diagnosis among providers and the possible acceptance of a more inclusive diagnosis. The unfortunate and inaccurate diagnosis of “atypical Anorexia Nervosa,” as the article suggests, will only feel dismissive and shameful to all people who are trying to fully grasp the severity and significance of their illness, no matter their body size.

The central issue is the lack of creativity and limited diagnostic categories for people with eating disorders. Over many years, I have seen people exhibit the same food restriction with extreme variability in weight. People in large, medium, small and emaciated bodies can all have very similar symptoms.

Each person is genetically programmed to respond to starvation and malnutrition in different ways. These metabolic changes induced by anorexia are the body’s attempt to survive a severe, prolonged famine. The resulting body size reflects how that body can survive such an assault.

However, it is naive to assume that everyone with restrictive eating behaviors but in different size bodies will experience their eating disorder the same way and respond the same treatment.

Because anorexia has a strong cultural association, people assume anorexia only applies to someone who does not eat and has an emaciated body. Because of the increased pressure for thinness and almost universal belief that dieting or undereating is virtuous and supposedly healthy, almost everyone risks inducing an eating disorder. Chronically underfeeding one’s body is the number one risk factor for an eating disorder, no matter the reason for restricting food.

But people who restrict in larger bodies will be misdiagnosed and often judged for their body size no matter how little they eat. And those in emaciated bodies often receive attention and even praise for the result of their eating disorder. The psychological ramifications of body size is very significant to an eating disorder and to the path of treatment and recovery.

Moreover, the physiological adaptations that lead to larger or smaller bodies when restricting are very different. Our metabolism can respond in many ways to adapt to the lack of food, and the overall course of treatment needs to be tailored to each person’s biological response to the illness.

No one can predict how a body will respond to severe restriction. The focus of diagnosis and treatment needs to be on behavioral, psychological and medical symptoms and include the effects of body size and weight as a part of the treatment. Discounting body size as a factor in eating disorder treatment is ignorant and misguided.

Eating Disorders and our Nervous System

A relatively new direction in psychotherapy is the discussion of our nervous system. Words such as activation and dysregulation of our nervous system describe increased anxiety or the experience of shutting down in response to external or internal emotional triggers.

Discussing our nervous system incorporates the idea that some responses to our lives are driven by ingrained reactions, not emotions or fear.

The referenced nervous system is the autonomic nervous system, an automatic and unconscious part of how our body functions. The autonomic nervous system regulates brain and body activity in response to threat and safety and changes how our body reacts to these different scenarios.

The key is that these nervous system reactions are automatic. Although we may create a logical explanation as to why we react the way we do, the story matches but does not explain the physiological and emotional response. Our bodies instead are programmed to respond to stress or safety in specific ways, but not the same ways for everyone.

Focus on the connection between the autonomic nervous system and mental health revolves primarily around the treatment for trauma. The underlying point is that the ways our bodies react to trauma are protective: we activate our fight-or-flight response or shut down in order to avoid as much harm as possible during the traumatic experience. The new theory helps people understand why their body reacted to trauma the way it did, how this response is protective and the cause of their current symptoms.

My question is how does the autonomic nervous system relate to eating disorders?

First, most eating disorder symptoms replicate the experience of shutting down. Restricting food, binging and purging all induce the feeling of shutting down our vigilance and cognitive abilities thereby numbing emotions and connections in the world. Eating disorders trigger a part of the autonomic nervous system that protects us by shutting down. When emotions or agitation are too strong, the quick fix of eating disorder symptoms can powerfully access shutting down.

Recovery and treatment demand being present, as I have written about extensively in the blog, and also emotional attunement with others, another core part of the autonomic nervous system. The vulnerability of the heightened awareness of being alive and connected to others often overwhelms people in recovery. The temptation of shutting down can be so powerful and lead to slips or relapse.

Even this simple framework opens up many questions. Is there a component of attunement and alertness that is overwhelming for people who get eating disorders in first place? Is there a predilection to seek the numb feeling of shutting down? Does the pull to shutting down reflect a reaction to prior trauma or to a life experience? Are people with specific types of autonomic nervous system more prone to eating disorders?

This new theory about mental health is applicable and useful for eating disorders. New conceptualizations of eating disorders are necessary. The current clinical approaches are often punitive and not helpful. Perhaps theories about the autonomic nervous system will open new doors to eating disorder treatment and care.

Separating the Forest from the Trees in Eating Disorder Recovery

A colleague and mentor of mine, who has treated people with eating disorders long before I started, said that it’s important to remember that these patients have never really been seen or heard. The experience of therapy that will most help them get better is feeling seen and heard for the first time.

As the eating disorder treatment world expands with residential programs, IOPs, meal supports and all sorts of groups, clinicians need to remember this tenet of recovery.

Patients almost always fell into their eating disorder by accident. A combination of the draw of dieting and weight loss, the accidental discovery that eating disorder symptoms serve a powerful emotional purpose and a genetic predisposition lead people into a cluster of symptoms that takes over their lives.

As the illness grows in mental and behavioral scope, the person finds themselves trapped in a life dictated by the demands and emotional rewards that come from following the eating disorder rules and behaviors.

However, this new world does not allow for the connection, affirmation and love one can find in relationships. The eating disorder serves as the arbiter of daily decisions, the guiding light for what is right and wrong and the ultimate assessment of your value as a person.

We are social people whose health and well being necessitate safe and secure interpersonal attachment. Without the ability to form strong connections, the eating disorder deprives people of not just continued nutritional sustenance but the source of emotional sustenance too.

Therapy is often the first time many patients find someone who sees them. The experience of someone listening to what you have to say, valuing your thoughts and feelings and exploring the true elements of what makes you the individual you is transformational.

Of course, eating disorder treatment must include normalizing meals and snacks, yet the importance of strong emotional bonds combined with the experience of being seen and valued is just as crucial to recovery. With all the new changes in eating disorder treatment, it’s important not to ignore what getting better really means.

Virtual Eating Disorder Treatment

Eating disorder treatment, like so many elements of health care, has adopted the virtual treatment model wholeheartedly. Virtual treatment programs, virtual meal support and access to care all around the country are increasingly prevalent and accepted. State licensing programs and insurance coverage are reassessing previous regulations. The lack of access to eating disorder care throughout the country is a relic of the past.

Virtual treatment was present before the pandemic and has taken on an ever increasing share of overall clinical care. The treatment community is in the process of transforming the care we provide and adapting effective methods to remote work.

The overall benefit of virtual care is straightforward. Most important is access to care throughout the country. Remote and rural areas used to have no care for eating disorders. That issue is in the past.

In addition, skipping or missing appointments is much less common so clinical treatment can be much more consistent. Moreover, virtual contact between appointments, important for many stages of recovery, is easily embedded into virtual care.

The potential pitfalls of virtual care are less obvious and important for the clinical eating disorders world to grapple with.

First, the screens create not only a physical distance but also an emotional one. The connection between clinician and patient is so important for recovery as I have written about extensively here. Developing that therapeutic bond is harder virtually. The screen creates distance that sometimes can be hard to cross.

Second, it’s easy for people to hide online on many different ways: hiding food, hiding feelings, hiding fears. Bridging the virtual gap is always possible and demands a different way of approaching treatment, an added vigilance of the clinician and increased awareness to piece together clues that are often more obvious in person.

I strongly advocate for virtual treatment and am positive the increased access, no matter the platform, will be beneficial for many people. In trying to explain some of the benefits and pitfalls, I hope the treatment community continues to figure out the best ways to make virtual care effective.

Eating Disorder Therapy Must Start with the Food

There are so many different directions to take when seeking treatment for an eating disorder. Even ten years ago, the options were so much more limited. Now there are many clinicians (even if it’s not always easy to find someone taking new cases), treatment programs and a variety of support networks online.

When making the decision about the first step, one element of the treatment is necessary: talking in depth and specifically about the food. Many patients I have seen worked in therapy for years making significant progress their lives. Unless the therapy focuses on part on the food, eating disorder symptoms just don’t change.

Of course, addressing the food is one of the hardest steps in recovery. To a person, people with eating disorders feel that discussing their food is the most exposing, most vulnerable thing they can do. So the clinician needs to gently urge people to understand why it is so important and also so hard to talk about the food.

If the food remains a secret, the thoughts and behaviors also remain hidden and outside the purview and potential benefit of therapy. Exposing the eating disorder thoughts and behaviors reveals the feelings covered up by the eating disorder and gives the therapy a chance to help find new ways to manage these emotions.

The willingness to discuss food is the most courageous step someone with an eating disorder can take in therapy. Freedom from these illnesses demands exposure of the symptoms and a desire, no matter how difficult, to let go of the needed comfort and safety.

Any successful therapy must address the food and will subsequently open up the possibility to learn new ways to live and thrive without the eating disorder.

Eating Disorder Classification Does Not Work

The diagnostic classification of eating disorders is problematic. Anorexia, Bulimia and Binge Eating Disorder are the only accepted diagnoses, yet many people with eating disorders, especially those struggling for many years, only fit into the box of Eating Disorder, Unspecified.

It may seem like these diagnoses shouldn’t be very important, but insurance companies insist on a diagnosis for reimbursement and treatment. Since insurance has so much power to dictate medical care, the diagnosis does matter.

Moreover, the diagnosis helps define the problem and lay out a clear path for recovery. Even if the clinical team insists that the diagnosis does not reflect the severity of the disease or importance of recovery, an unspecified diagnosis feels demeaning and dismissive and often decreases the motivation for a patient trying to take their illness seriously.

The diagnostic criteria need to take into account the shift in symptoms through the course of an illness in order to help describe the various disorders more clearly. For now, the classification only describes the earliest symptoms of illness.

For instance, people with anorexia in the first couple of years meet the criteria for weight and eating behaviors, but many fewer continue to do so for five years or more. The body biologically tries to survive the illness by finding ways to compensate for long-standing food restriction or by slowing metabolism to conserve energy. Thus, people with chronic anorexia usually don’t meet the weight criteria after a number of years, a very demoralizing and misleading change. However, even through these adaptations, it’s clear to any clinician the person still has anorexia, just in later stages.

The same can be said about all eating disorders in many different ways. The diagnoses don’t distinguish the myriad ways eating disorder present and persist.

Formally clarifying the distinction between stages of illness would not only be illuminating but also help patients better understand their diagnosis and how to conceive of treatment.

The best next steps in diagnosis would be to create stages of illness that allow people to recognize their diagnosis and also where they are both in the course of the disorder and in recovery.

What it Takes to Really Get Better from an Eating Disorder

Eating disorders usually start at a young age and become a central part of how a person functions early in the development of our identity.

The eating disorder rules organize daily life around food and weight, sets a clear and definite idea of right and wrong and helps life make sense at a confusing developmental period.

Eating disorder symptoms serve as an easy and effective way to manage feelings and calm oneself down during periods of distress.

Eating disorders become central to identity. It’s acceptable to conflate an eating disorder with personal goals, personality and a legitimate organizing force in life.

By the time the eating disorder becomes a problem, one’s entire life and self-image is organized around this illness. In fact, the eating disorder often doesn’t feel like an illness. Questioning the eating disorder usually feels like a personal attack instead.

Recovery doesn’t mean getting better from a long-standing illness to most people. It feels like tearing away the fabric of their being. It feels as if clinicians are asking them to remake themselves, to start from scratch.

So getting better from an eating disorder only begins with a stable meal plan, regular meals and snacks. Recovery quickly becomes more of an existential crisis, a journey to figure oneself out and to throw out the old theories.

Anyone starting recovery, and any clinician embarking on this path with a patient, needs to be aware of how disorienting and exposing recovery feels. Getting better means opening up some of the deepest personal spaces and looking at the raw emotion and fears that are revealed by the end of eating disorder symptoms.

The process of recovery demands respect, empathy and creativity. The path often leads to unexpected places, figuratively and practically, and can end up at unpredictable realizations about life.

Only with a knowledge of recovery and a willingness to explore what the person needs to face, without judgment or criticism, can someone find their way to being truly well and to being truly themselves.