Please Stop Saying Eating Disorders are about Control

The word control is used so often as a shorthand to describe the fundamental basis for eating disorders. The most obvious implication of this word is that an eating disorder imposes control on an unpredictable and confusing world. However, using this word blithely ignores some central truths about eating disorders and also tacitly condones them as reasonable and useful. Thus, the idea of control is frankly dangerous for those in recovery.

First, the idea that we can control our lives or our worlds is inherently absurd. Life is unpredictable and complicated. The daily events of our days may appear to be connected with our choices, but so much of what we experience is a reaction to the world around us, almost all of which happens irrespective of how we live. Certainly the pandemic makes this reality very clear.

Second, eating disorders don’t lead to increased control of our daily lives. This sentence reveals a deep misunderstanding of the nature of an eating disorder. When an eating disorder is unchecked, it dominates a person’s life. Frequently, people describe feeling dragged from one experience to another by the power of the eating disorder without any sense of agency at all. In fact, eating disorders drain our identity and will, all for the sake of food and weight. Any ability we have to influence our lives disappears when an eating disorder is powerful in a person’s life.

Third, the word control is used to replace the desire for for certainty. If a person listens exclusively to the eating disorder thoughts, life is predictable. The days are painful and monotonous but not a surprise. The eating disorder dominates each day, dictates all decisions that need to be made and creates a plan for how to live each day that is both very constrained and very familiar each day. Life is unchanged and limited, and also very predictable. This is not control but psychological torture.

The last reason the word control is problematic is that it conveys a sense of mastery about daily life. Control implies a sense of accomplishment around the eating disorder when life with this illness actually feels like misery and failure.

Vocabulary choice to describe mental illness is very important. Choosing a word with different connotations dangerously glorifies an illness that ruins peoples lives. Control makes an eating disorder seem helpful in a complex world. In fact, an eating disorder takes away all agency and only causes unhappiness. Let’s not use the glorification of how we manage food as a way to only cause more illness.

Antipsychotic Medication in Treating in Treating Disorders

In residential treatment centers patients with eating disorders are increasingly prescribed antipsychotic medications. This trend is alarming since most patients are unaware of the long-term, and possible irreversible, risks and minimal evidence of benefit.

First, there is limited and unconvincing data that antipsychotics help in eating disorder recovery. Initially, about 20 years ago, many of these medications were prescribed because of the side effects of increased appetite and weight gain. The clinical reasoning was that weight would help with recovery. In fact, the opposite is true. The side effects only galvanize the eating disorder thought process and lead to immediate return of symptoms after discharge.

Currently, this class of medication is used because of the theory that it will decrease obsessive thoughts about food. Again there is no compelling evidence to justify this conclusion so the next logical step is to question why antipsychotics are prescribed so liberally in treatment programs.

The first reason is the overall difficulty of treating eating disorders. The frustrations, especially around medication efficacy leads prescribers to search for any medication that may help. The truth is that medications only help with symptoms peripheral to eating disorders such as depression and anxiety. If prescribers accept this reality, they will quickly curtail use of antipsychotics.

The second reason is the hidden expectation of increased appetite and weight gain. Frequently, patients aren’t told this is the case which in and of itself is unethical. Any change in appetite and weight gain will give the illusion of recovery and hasten discharge. These decisions clearly don’t help recovery or long-term health but only serve the immediate purpose of the program.

The third reason is the pressure from pharmaceutical companies. Because these medications are expensive, it behooves the companies to encourage increased prescribing. Clinicians need to be aware of the lack of evidence that antipsychotics help with eating disorder and only use them when warranted.

None of the reasons for increased antipsychotic prescribing for people with eating disorders enhances recovery. And in order to make these medication decisions, most patients are unaware of the potential side effects.

Increased appetite and weight gain are common side effects with all medications in this class. The unwanted changes only solidify the eating disorder thoughts and prolong the path to recovery.

Antipsychotics can affect reproductive hormones significantly and disrupt regular hormone fluctuation through the month.

These medications can also cause movement disorders such as muscle stiffness, agitation and restlessness which are very uncomfortable. Although a rare side effect, tardive dyskinesia is a permanent movement disorder typically consisting of involuntary movements of the fingers, toes or mouth. Very occasionally, people can develop tardive dyskinesia from just one dose of an antipsychotic.

An important step for treatment programs is to recognize the value and limitations of medications to treat the symptoms of eating disorders. Overprescribing antipsychotic medications with concerning side effects needs to stop. Oversight at the programs by more experienced clinicians can alter these practices quickly.

Abandoning Your Eating Disorder

Eating disorder recovery is often described in positive, self-affirming words: a triumph, the road to a better life, a battle worth fighting for or a way to save yourself. It’s easy to couch a very challenging path in phrases that feel victorious and that lead to a new wonderful existence. However, these words belie the challenges and realities of what real recovery looks like.

The nature of an eating disorder is to be tightly woven into one’s self worth and identity. So recovery can feel like ripping away a central part of who you are. If it is clear how much pain and suffering the eating disorder causes, people will understand what the process is like and can see more clearly how they will get better. The idea that recovery is somehow wonderful and easy could not be further from the truth.

Extricating oneself from the idea that you are the eating disorder is a painful and tortuous process. It feels like losing a piece of oneself and saying goodbye to a central part of your being. Despite the torture of the eating disorder, the thoughts, symptoms and rituals provide structure and solace throughout the day. They make one feel productive, comforted and safe. They create rules that otherwise don’t exist. They provide a feeling, no matter how false, of accomplishment at the end of the day.

Without the grounding and soothing of the disorder, life feels confusing, aimless and pointless, at least until one can see how other parts of life can be fulfilling and meaningful. Recovery demands the need to find other important parts of life to replace the disorder, like friends, work, passions or hobbies, that can feel grounding in and of themselves without the eating disorder. At first, it feels like nothing can replace the eating disorder, but over time other elements of life do begin to matter.

I recently read Evanna Lynch’s memoir, a large part of which is about her eating disorder recovery. She says many astute things about recovery. The one that stands out to me the most is that there is no bargaining with an eating disorder. As long as you bargain, the eating disorder always triumphs. The only way to get better is to abandon the eating disorder, as if leaving it by the side of the road to die on its own. As painful as this step is, it’s essential to find a place inside oneself where the eating disorder rules and thoughts just don’t matter anymore. It’s a painful and lonely place at first, but it leads to a new way of life that has its own rules and eventually joys. The pull to the simplicity of the eating disorder may linger, but life takes over in surprising ways when you let go.

This is a novel thought because she does not sugarcoat recovery. She talks plainly about how difficult it is. And she also describes a clear but painful path to getting better. It’s better for someone embarking on recovery to know the truth.

Approaching Someone in Recovery

Eating disorders at their core are an attempt to cope with the world around us and with our feelings and thoughts. The core beliefs of an eating disorder structure each day with goals and plans to feel comfortable and secure. In a world riddled with uncertainty and fear, an eating disorder simplifies life and guides us through our daily travails.

Naming an eating disorder as an illness simply ignores the fundamental purpose it serves. We all struggle with how to manage our thoughts and feelings, fears and dreams. It’s not as if any clinician has the perfect way to face the realities of life. Yes, eating disorders wreak havoc on one’s life and on those around you and so aren’t particularly effective. But the alternative of learning to live without the eating disorder is no easy feat either.

No one should tell someone in recovery that life will be wonderful once you get better, that recovered life is a type of nirvana. Realistically, life in recovery is still hard even though it is very much possible to get well. Life in recovery does mean being able to face daily tasks, develop much closer relationships and learn to achieve goals outside of food and weight. Eating disorders make other life goals almost impossible.

But recovery does not make things easy, just possible.

Treating people with eating disorders as less than or inferior is infuriating to people in recovery. Even for the sickest people, everyone wants and needs to be treated as an equal human being. Eating disorders don’t make anyone less than another person. Having fallen into an illness that helps one cope with life is not a sign of failure or a less evolved person. We all cope with life the way we do. If someone gets off track with an eating disorder, the goal of recovery is to find another way.

So in order to connect with someone getting help for an eating disorder, the best way to approach any conversation is just as two people trying to talk to each other. Recognizing the underlying humanity in another person, no matter their situation, is the best way to work together and help open a path to get well.