How to Prevent an Eating Disorder from Becoming Chronic

The last two posts made a few things clear. Almost everyone is exposed to the risk factors for developing an eating disorder: dieting and adolescence. In addition, most people have an evolutionary predilection towards starving or binging. The combination of these variables leads some people into the prodrome, the precarious mental state that precedes the eating disorder, and then into the illness itself. There are two critical questions to answer in order to fully understand the prodrome: who recovers from early illness? and how to prevent the progression to a chronic disorder?

I don't want to minimize any stage of an eating disorder. The symptoms hijack the patient's life and overturn any semblance of a stable family. However, the early stage of an eating disorder is critical because there is still a significant chance of full recovery.  Eating disorder treatment for patients in the acute, early illness involves weight restoration, normalizing eating and a return to regular life. For most patients, this transition is very hard but often a relief from the physically and emotionally punishing cycle of the illness. For most, this treatment is enough. The difference between recovery and chronic illness is comorbidity--the presence of another psychiatric disorder in addition to the eating disorder. When the eating disorder masks the comorbid disorder, normal eating leaves the patient fully exposed to the comorbid symptoms. In fact, the eating disorder becomes a very powerful and successful coping mechanism for the underlying problem. Following the rules of the eating disorder gives a sense of control and satisfaction. The world is ordered and makes sense. The other disorder makes little sense and has no rules. Under these circumstances, the patient with comorbidity will choose the eating disorder, essentially the lesser of two evils. After "failing" at treatment, this patient will quickly be labeled chronic.

The most common comorbidities are trauma, depression and anxiety. A history of abuse, particularly as a child, contributes to a strong need to hold onto the eating disorder. Like an abusive parent, the eating disorder provides both comfort through eating and punishment through the  internal monologue that is harsh and unrelenting. The  eating disorder hides her fear that she will be subjected to more trauma. This calms the feelings and memories of the abuse and structures the patient's adult life. Depression and anxiety often accompany the descent into the illness, but a minority of these patients have severe depression or anxiety as the primary symptom. In these circumstances, fully treating the comorbid symptoms will also largely cure the eating disorder. Conversely, untreated or undertreated depression or anxiety will lead to chronic illness: the eating disorder helps the patient manage her other symptoms.

There is one more category of patients who become chronic. I will label them as the "delusional" type. Here the comorbidity could be seen as part of the disorder, but I prefer to label this aspect of the illness as separate from the eating disorder itself. The delusion reflects the patient's inability to differentiate between the most punishing and extreme thoughts and behaviors of the eating disorder and reality. There are many examples: some patients literally see themselves as 100 pounds heavier in the mirror, some are convinced they have eaten calories when they drink water or even by watching others eat, others truly think the eating disordered thoughts will punish them, some don't believe they are sick at all. These patients lack the perspective to see the disordered thoughts as part of the illness. Recovery makes the patient feel as if she will lose herself. Her identity is woven into the disorder so that she does not know herself without it. Needless to say, the treatment course is significantly prolonged.

What can be done to prevent the patient from developing a chronic eating disorder? A thorough initial evaluation followed by a  comprehensive treatment plan will identify those people at higher risk to determine who needs treatment for the comorbid illness as well. This involves trauma therapy concurrent with eating disorder treatment
or comprehensive treatment for depression and anxiety. For the patient with a delusional comorbidity, the treatment is more complex. This patient may end up in several rounds of treatment, often both inpatient and outpatient, before she is accurately diagnosed and finds the right help. The key to success is a strong therapeutic bond which can generate the internal motivation and courage needed for the patient to question the delusions. In addition, the treatment must nurture the growth of the patient's identity separate from the eating disorder. This is no easy task but is critical for real recovery. The delusional comorbidity also can break down even the most supportive families. Their role is to work hard to find the best help for their daughter. Participating in the eating itself is almost always  counterproductive unless supervised and instructed by the treatment team. However, families can and must provide emotional support and compassion through the treatment. The process is long and arduous, and families themselves may need support to handle their own frustration.

Writing about this critical part of the evolution of an eating disorder has led me to address the role of the family. Most patients in the prodromal stage are in their teens or early twenties and are still dependent on the family for support. The next post will address the best ways for families to support the child with an eating disorder.

Hunger and Fullness

Hunger and fullness are the internal cues we use to regulate eating. They are also what our current culture of abundance of food and obsession with thinness looks to exploit. Last, they are what goes awry in an eating disorder. Relearning these cues is a cornerstone of eating disorder treatment.

At the most basic level, hunger is critical to our survival. It is clear that identifying hunger and acting on it is necessary to avoid starvation and death, both as an individual and as a species. Most of us feel mild hunger on most days, but hunger need not be a regular part of daily life for a majority of the population anymore. Experiencing hunger seems more like a social statement--or even a medical condition--than an evolutionary necessity. But forced hunger and starvation are very different. Prolonged hunger leads to a primal, visceral response which includes obsessive thoughts about food, a voracious ability to eat endlessly, cravings for odd food combinations, mindlessly performing strange food behaviors and a complete loss of rational thought around the social norms and propriety of eating. In other words, anyone who is chronically starved exhibits the symptoms of anorexia nervosa. This point highlights another curious aspect of eating disorders. Anorexia looks more like an adaptive mental state in starvation than a psychiatric illness.

It is less clear what role fullness, or satiety, plays in our lives. Historically, eating until one was full, very full, was looked upon as socially correct behavior. If there was an erratic food supply, eating a lot was a way to store energy for the future. Eating large amounts and gaining weight was a sign of prosperity and wealth. The expression of love and caring in many cultures is through providing food and eating together, usually to excess. Similar to anorexia, overeating or binging looks like an adaptive response to an environment with excess resources: eat and eat and eat. It is a physiological response to help avoid hunger in the future.  Calling it a binge is a new classification of an old, adaptive behavior. Any compensatory action to repair the "damage" done by the binge, i.e. purging, are panicked responses to the social judgment and perceived consequences of the binge. Fullness has no clear relevance to survival. There has been little reason to hone our instincts to identify fullness, at least until now. Bombarded with a neverending supply of food crafted to appeal to all of our senses, fullness is now necessary to avoid overeating and obesity. In that vein, fullness is not adaptive at all. It is a social construct created because of our ideal of thinness and a culture serving up endless quantities of food. Our society acts as if fullness is a natural instinct, and by extension a failure for those who cannot recognize it, not an ingenious way to place responsibilty for the obesity epidemic upon the individual.

Like all adaptive, evolutionary traits, hunger and overeating are exhibited along a spectrum. Some people will experience the starvation response more quickly and profoundly while others can tolerate hunger and function. Some will gorge around excess while others will not be capable of overeating. From an evolutionary standpoint, this variability within a population ensures the survival of a species. Certain people will survive in famine and others will prosper in times of excess. In modern times, these traits transform from evolutionary traits into eating disorder risk factors. Suddenly, people who can withstand hunger try a diet and find that their tolerance for hunger is rewarded by society and by the internal, visceral high of starvation. Others who have the adapted trait to overeat when food is abundant find that the food industry products trigger a primal craving, such as sugar cravings or carbohydrate cravings. In our current culture, it is a short leap from evolutionary leanings to a full-fledged eating disorder.

If risk factors for an eating disorder are adaptive traits, where does that leave those most susceptible? If we live in a world with food aplenty and processed food designed to appeal to our most basic desires, how can those susceptible not get an eating disorder? How effective can intuitive eating--a treatment designed to help us get back in touch with our internal sense of hunger and fullness--successfully compete with evolutionary adaptations? These are sobering thoughts. They leave eating disorder treatment in a bind between our most basic instincts and the missteps our society has made about how we handle food.

Although I am tempted to address the larger picture first, I want to stick with the original point of writing this blog: the treatment plan. So the next post will look at the transition from adaptive response to eating disorder. As I described in the last post, it is called the prodrome.