Why People Love their Eating Disorder

Unlike most psychiatric illnesses, and most medical ones too, eating disorders are ego syntonic, a psychological term which means that the central thoughts of the disorder feel right and good, something crucial to one's ego. Based on my recent posts about the harsh thoughts associated with eating disorders, this idea may seem contradictory, but the negativity of the thoughts only become clear once someone starts recovery. Before that, as long as the person obeys the thoughts, the disorder makes a confusing and scary world very calm and peaceful, even as the illness destroys any chance at living a full life. 

It's hard for most people to understand how an illness can feel good, and therein lies much of the public confusion about eating disorders. 

The evidence abounds for this inherent trait of eating disorders: websites extolling the virtues and successes of having an eating disorder, the misguided envy of many adolescents of their peers with anorexia or bulimia, and the tenacious grip the person maintains on her eating disorder as a lifeline to safety. And that is just to name a few. 

Unfortunately, the nomenclature for eating disorders largely ignores this critical component of this group of illnesses. The list of symptoms focuses on restricting food, binging and purging with only a minimal reference to the powerful attachment to the illness and the lack of insight into the severity of one's impairment. 

Focusing on the eating symptoms themselves remains mystifying and intriguing to laypeople. The urge to resist eating and use compensatory behaviors to avoid digesting food masquerades either as a successful diet choice or completely perplexing behavior to people ignorant about these illnesses. The vast majority of available knowledge omits the intense connection between the ill and her disease, thus ignoring the central reason people cling desperately to their illness and the resulting difficulty of recovery. 

So the struggle between the afflicted person and her family and friends stays focused on the food. The struggle between external pressures to eat cannot directly compete with the powerful personal connection to the illness. Any successful intervention has to challenge this connection and reveal the lies that sustain it, not just convince the person to eat dinner. 

The calm and peace that comes with feeling together and close to the illness stems from a web of lies. The eating disorder limits personal life significantly. Although some people can enjoy some success, especially in the academic or professional arena, the end result is a severely limited existence. The opportunity for close relationships, personal connections and the full range of human emotions doesn't exist. The urge to engage in the eating disorder symptoms and retreat from life dominates daily life. 

The thought process that keeps someone attached to this existence repeats the same messages over and over: relationships are not reliable; people always disappoint you; you have figured out how to stay skinny and that's most important; nothing will ever work out for you; you're not worthwhile enough to anybody; no one really cares; I (the eating disorder) will protect you.

These thoughts feel absolutely true which makes the need to stay close to the eating disorder even more important. The way to challenge these lies is not to implore someone to eat. That only fuels the eating disorder further. An effective approach is to challenge the lies again and again, to point out that the lies themselves keep someone so sick. 

The next post will explain how someone escapes the ego syntonic experience of an eating disorder in recovery and how family and friends can support the process.

Ways to Counter the Eating Disorder Thoughts

The last post explored the power of eating disordered thoughts and why they exert a strong grip on people trying to recover. It's difficult for people without these illnesses to comprehend how thoughts about not eating can dominate one's mind. The combination of a seemingly inescapable thought process and the inexplicable nature of the mental illness leads to extreme isolation and despair. 

I realize that presenting the last post without some guidelines to face the thoughts can appear to be fairly demoralizing. 

There are three main ways to manage these thoughts through recovery: personal relationships, honesty and replacement thoughts. Although the concepts are relatively simple, putting them in place daily against automatic thoughts of the eating disorder presents one of the major challenges of recovery. 

A person fully engaged in the eating disorder with no intent of recovery finds the eating disorder thoughts largely comforting. The thoughts themselves may be harsh and critical, or even nonsensical, but they present an easy roadmap to follow for a predictable daily life. As long as the thoughts go unchallenged, the person experiences an enormous amount of comfort, often described by many as a best friend or partner. 

The existence of a risk-free relationship to an internal set of rules tends to obviate the need for any true relationships. The relationship with a thought process feels very real and predictable while real relationships are unpredictable and scary simply because they involve another person with their own thoughts, feelings and needs. 

There are obvious needs an eating disorder cannot fulfill, and even a small step into recovery exposes the incredible loneliness right below the surface of the illness. Opening one's mind to wellness involves re-engaging in relationships. The process of establishing and deepening those connections weakens the eating disorder thoughts each day. One step in facing the thoughts is consciously making the effort to create true connections in the world which highlight the emptiness of the illness. 

The thoughts thrive on secrecy and lies both to people in the world but especially to oneself. The fundamental messages of an eating disorder are similar for almost everyone: you don't really need to eat; you have found the comfort you need so who needs other people; people always let you down; the eating disorder is the best thing you'll ever have. These internal thoughts become one's reality. The sense that these messages are lies no longer rings true.

Either talking to other people or in relation to oneself, these lies are the basic philosophy of life. They become the bedrock of how to function day to day and lead to a life full of the illness but little else. Constantly working to question these lies and instead start to believe the reality of the eating disorder as an illness critically weaken the thoughts over time. 

By creating parts of one's life separate from the eating disorder, the person in recovery can recognize and identify other daily events and thoughts that compete with the eating disorder thoughts.

The person in recovery starts to be able to identify eating disorder thoughts as part of the illness rather than automatic, true facts. In doing so, it becomes possible to replace the illness thoughts with other realistic thoughts about daily life. This will weaken the thoughts as well and render them much more powerless in time. 

There are many steps in recovery that allow a person to face the eating disorder thoughts and continue the road to wellness. It's crucial for family and friends to work hard to understand the power of the psychological part of these illnesses and acknowledge the challenge of getting well. As the person better understands the ways to counter the thoughts, it will be easier to communicate their struggles and need for support. The better one understands this component of recovery, the more hope one can have of getting well.

Eating Disorder Thoughts

Most of the focus on eating disorder treatment is on the eating behaviors themselves. They are a concrete representation of complex mental and physical illnesses and present a facile way to explain the complex recovery process. It remains clear that powerful psychological barriers make the practical changes extremely difficult.

This obstacle stems largely from the conflation of personal identity and the eating disorder. Two facts about eating disorders make this condition likely. First, since eating disorders emerge at the same time as identity growth during adolescence, the objectives and thought patterns of the eating disorder feel like a personal philosophy. Second, the eating disorder rules boost self-esteem and help buoy internal confidence, and are called in psychological terms ego syntonic. 

Thus, an important part of recovery is the separation of one's own individual thoughts and identity from the eating disorder thoughts. Since these two thought processes grow together, the person has a lot of difficulty distinguishing them. Thus, the separation is a tall order. 

The concept of eating disorder thoughts is very abstract to people without eating disorders. In fact, the range in quality, strength and tenacity of these thoughts is broad. For some, the thoughts are a construct to conceptually separate identity from the eating disorder, yet the thoughts have no real mental manifestation other than arbitrary rules. For others, the thoughts feel like an entity unto themselves. When disobeyed, these thoughts turn into screaming, critical accusations and punishment in one's mind.  In these cases, the thoughts aren't just rules to follow; they feel like an actual mental presence determined to destroy any sense of peace if not followed completely. 

The eating disorder thoughts run along a spectrum between these extremes. For people with less powerful thoughts, treatment and nourishment can be sufficient to weaken the thoughts and lead to recovery. The stronger the thoughts, the increased difficulty of fighting and questioning the thoughts, even after periods of normal eating, and the longer and more painful the recovery. 

Little has been written about eating disorder thoughts through the process of recovery. Certainly, starvation and malnourishment worsen the thoughts considerably. Also these thoughts tend to be insidious and find ways to adapt to changes in recovery. They also are always very categorical, absolute and punitive. The process of questioning the thoughts is exquisitely painful for anyone in recovery. It means enduring long stretches of internal screaming each day, every day for an extended period of time. When following the thoughts, that person feels calm and soothed. Without these thoughts, it feels like there is no other way to feel a sense of calmness, so the internal punishment is accompanied by an inability to find calm in any other way. 

Over time, recovery will lead someone to new ways to find internal peace and open up exponentially more opportunity for fulfillment in daily life. However, even with that knowledge, the long and painful transformation from comfort in the eating disorder to knowledge and experience of a healthy life is excruciating and can be terribly difficult to navigate.

Hearing about others' road to health can be inspiring, yet recovery involves a leap of faith in facing down the thoughts day after day without immediate benefits. The end result is very different from life with an eating disorder. But it's worth it.

The Primal Nature of Hunger and Fullness in Eating Disorder Recovery

Clinicians in the eating disorder world frequently refer to hunger and satiety as basic survival mechanisms gone awry as a primary effect of these illnesses. Normalization of eating patterns through meal plans and portioning can retrain one's internal clock to reset.

But for many people in recovery, attempting to reprogram eating patterns feels more like a stroke patient learning how to walk again than approaching a new skill like yoga or knitting. In other words, it's much more challenging to change ingrained, automatic behavior patterns than to pick up new abilities. 

The reason behind this difference lies in levels of brain function. Some brain activity is basic and primal. It's shared by most mammals, which means that it developed millions of years ago, long before the differentiation of mammal species. These include sleep patterns, walking, fear response and hunger and fullness. 

Humans, however, have a significant percentage of the brain, mostly in the frontal cortex, that is vastly different and more complex than other mammals. This part of the brain coordinates planning and a variety of abstract functions lumped together into something called higher order functions, basically only actions humans can accomplish. These activities and behaviors can vary from technology to agriculture, literature to fine arts, or knitting to yoga. They are consciously learned activities that take practice and attention to master, clearly different from the automatic, ingrained actions of the more basic parts of the brain. 

This newer part of the brain is much more adaptable. We can use these abilities to learn and grow throughout our lives. Changing behaviors that are higher order functions take time, attention and practice. Any alteration in the more primal, basic functions can feel almost impossible. These actions are so ingrained, so automatic that we almost begin to conflate them with our actual selves. How we walk, sleep and eat simply defines the foundation of daily life. 

So, with a primer in different types of brain function, the recovery adage of retraining hunger and fullness seems inadequate to describe the enormity of the task. Any alteration in such a basic function demands constant attention. Any lapse opens the door for the automaticity of old disordered behaviors and a return to what that person knows and has long been comfortable with. It's no wonder recovery makes the other daily chores of life so difficult. There's no room to let up without slipping back into old patterns. Resetting years of established routines in one of the most basic human functions demands an extended period of making these new thought patterns and actions automatic. 

This functional explanation of the obstacles encountered in eating disorder recovery gives another reason to explain why recovery feels like an identity transformation. If we define ourselves in part by how we go about our daily routine, then such a massive change in routine will feel completely disorienting. Anyone who has experienced a significant change knows how off-kilter it feels to lose the foundation of knowing the ins and outs of daily life. Changing jobs, moving to a new city or even just a new home leads to months of disorientation. Transforming one's daily interaction with food, one that has defined much of life, is like stepping into a new world. 

This explanation for the difficulty of recovery can also help patients understand why recovery must be life's top priority for a period of time in order for that person to get fully well. Since it takes full concentration and attention to change basic functions, such as eating patterns, other distractions will by definition allow the old disordered patterns to continue. However, an extended period of time focused on making these new patterns the default way to eat will give that person the time to normalize the new eating behaviors. Then, upon returning to normal life already practiced in recovery, it's possible to enter a new daily routine with regular eating.

The First Meeting with an Eating Disorder

Dr. Michael Strober, the director of the UCLA eating disorder program and a mentor of mine, wrote a seminal article (* link below). about how to approach the initial consultation with a patient with Anorexia Nervosa. I first read the article, written in carefully chosen, beautiful language, many years ago. As much as Dr. Strober was able to clearly explain the intricacies and demands of such a complex first meeting, the meaning of his words has only deepened with time.

It's a monumental challenge to alert a patient's eating disorder that the jig is up, a fencing match with the most subtle but effective of parries can set the patient on a path towards recovery, even someone seemingly unreachable. The practical effects of recovery may not be apparent for some time, but the first meeting can lay the groundwork for real change. 

I have since spent many hours wondering about the ramifications of Dr. Strober's discoveries. Although people with eating disorders are unique individuals, their illnesses are remarkably similar, and the message they need to see a path towards wellness practically identical. 

The eating disorder is so much more than the sum of its parts. It's a companion, a best friend, a lover and an all-knowing philosopher. It's a captor, abuser and torturer. It's a source of pride, an accomplishment in a sea of failure and an endless series of distorted mirrors. It's the primary basis of identity but also eclipses any true identity at all. 

It's everything one could dream of, yet it's also an illness, a common one at that, just like everyone else's eating disorder.

It's a vast emptiness. It's nothing. 

Dr. Strober states very clearly that a personal connection, one that obviates the need for the eating disorder, suddenly and completely calls into question the nothingness of this disease. The strongest eating disorders become personified, much like the personification of animals or inanimate objects in fiction.

Questioning that fallacy with an immediate and powerful personal connection can so disarm the patient that she can do little but listen in the open-minded way the illness had previously made impossible. 

What has struck me even more in the intervening years are the implications of that initial connection, the first moment of meeting an eating disorder.

It insists on the creation of a true and real relationship. It opens the door, if the treatment is to be truly helpful, to a very real and powerful connection, something both therapeutic and affirmingly existential at its core.

That powerful moment needs to be much more than a chance encounter. It insists on the need to see the special, moving and cherished characteristics of both the person and the relationship. It lays bare a vulnerability of a most profound nature. It creates a truly special bond risen from the ashes of a devastating disease, something lasting, a way to envision closeness in a world without the disorder. 

And in the wake of that intensity, pain and persistence against a wily and stubborn illness lies the foundation of a life in recovery, one that allows for the joy, pain, accomplishment and failure of an ordinary life.

That life no longer has the artificial drama and specialness of the eating disorder. It eludes the appeal of the supposed creation of a superhuman but false persona. After that devastating nightmare of an eating disorder wanes, what's left is a life that is very, very real.

The moment of meeting an eating disorder is now precious to me but fraught. Weighed down with the possibility of showing a very ill person a path towards relief, I see the import of Dr. Strober's words more clearly each day.

Eating disorders take away years of people's lives and cause endless suffering for so many patients and families. In that first meeting there is a chance to avoid years of pain.

If at all possible, I just can't pass up the opportunity to help someone escape that much suffering. 

* http://books.google.com/books?hl=en&lr=&id=3gmogQshI_MC&oi=fnd&pg=PA229&dq=Consultation+and+therapeutic+engagement+in+Severe+Anorexia+Nervosa&ots=WImTG6btD-&sig=qMblJkkRDMO69BLjiqjyoCOrM_s#v=onepage&q=Consultation%20and%20therapeutic%20engagement%20in%20Severe%20Anorexia%20Nervosa&f=false

Adolescence: a Risk Factor for Eating Disorders

Adolescence is a time of physical, mental and emotional growth. The rate of internal change is so fast that mistakes of poor judgment are inevitable. In fact, one of the last parts of the brain to mature involves planning and judgment, qualities clearly lacking for most teenagers. Combine this decision-making difficulty with the penchant for exploration and much of the risk for teenagers is perfectly clear. 

In every generation, there appears to be a new, tantalizing frontier that transforms into a universal rite of passage for adolescents. Alcohol, drugs and sex are the three most common concerns, but others have crept in like prescription pills and self-harm such as cutting. 

One of the newest adolescents crazes is the drive for thinness. With the expectation for both boys and girls to have unnaturally thin bodies, especially unnatural during the hormonal shifts of puberty, the appeal of weight loss has grown into a standard experience for teenagers. Peer pressure to restrict food, purge meals or take pills such as Adderall, laxatives or diuretics have grown almost unavoidable. Kids can find any number of weight loss guides on line as well to steer them towards these dangerous behaviors.

The thrill of seeing an effect on one's body can be exhilarating to a teenager who feels like life is an out-of-control roller coaster. The sense of pride and accomplishment, albeit one that is small and in the long run meaningless, quiets the constant feeling of confusion and replaces struggling self-worth with an immediate burst of confidence.

It's scary to reflect on just how powerful the drive for weight loss can be in adolescence and how success feels downright magical. 

As with all of the destructive behaviors for teenagers, the long-terms risks always escape their notice. Engaging in eating disordered behaviors, especially restricting food, sets off a cascade of biological and psychological responses to starvation.

No one can predict how each child will respond. No one knows if that child will just give up after a day or two, get caught in a cycle of restricting and overeating or be genetically susceptible to develop anorexia. But the increasingly common exposure to starvation for teenagers means those kids are more and more likely to find out. 

Until recently, no one would even consider these risks for a child. Eating meals through the day was a matter of course and the drive for thinness nonexistent. Accordingly, the incidence of eating disorders was very small, a rare and mysterious disease people fell into without any idea what was happening. That's not how eating disorders develop anymore. 

Adolescence has become a breeding ground for eating disorders, replete with friendships encouraging the behaviors, online groups dedicated to provide support and the social normalization of irrational food restriction. Just as drinking or using drugs at a young age can set that child up for much larger problems, food restriction increases the risk of developing an eating disorder. 

However, parents and adults are much less likely to worry about a teenager dieting than about using drugs. Those adults may themselves be restricting food or even encouraging the child to eat less. The social norms actually span generations, leaving teenagers without any idea their behavior is dangerous. The general obsession with thinness leaves children at sea to find a sane way to understand food and weight. 

With teenagers dieting and engaging in eating disordered behaviors, there needs to be a public health campaign to counter the false advertising of the food and diet industries. More specifically, children need to understand the risks of their behaviors and the expected norms that will keep them safe.

Adolescents won't necessarily follow the rules because that's the nature of the stage of life. However, exposure to the risks and norms will at least offer them some guidelines to either heed or ignore. It will allow them to know when their decisions are leading them into trouble. It will also give parents, even those struggling with food and weight, a means to teach their children a saner attitude about their bodies. 

But who understands these risks enough to spearhead the campaign? And who has enough influence to create awareness of these risks? The next post will address these larger questions. 

The Politics of Eating Disorder Treatment

Institutional health care--hospitals, rehabilitative centers, nursing homes and outpatient clinics--has undergone a transformation in the last decade from independent entities to large business. In order to have bargaining power in the marketplace with health insurance companies, institutions had to merge and garner a significant market share in their local community.

The most concerning issue with large health care business is consistent quality of care. Executives have increasingly relied on evidence-based medicine as the standard of care to show how even large institutions can provide excellent clinical treatment at all of their medical sites. 

This sea change in medical practice--large business and evidence-based medicine--has skipped mental health care which continues to exist in a world of solo practitioners and treatment centers. In fact, mental health treatment has often remained independent of the health insurance industry as well, except for the poor, the disabled and people with eating disorders.

As the spread of eating disorders breaches socioeconomic boundaries, too many patients don't get adequate care due to insurance limitations. And independent entities--clinicians or residential programs--have no purchase to bargain with health insurance companies. 

The new business model for the health care industry finally appears to be coming to the eating disorder treatment world. The Affordable Care Act provides one boon to the transformation: federal parity for mental health treatment. Any plan under the ACA must offer equal coverage for medical and psychiatric care, including treatment for eating disorders. Thus, one major bargaining chip for the insurance industry to limit care is no longer viable. 

The current trend is for well-known eating disorder programs to franchise residential and outpatient treatment centers in parts of the country with fewer resources. But eating disorder treatment remains complex and doesn't have evidence-based guidelines that are widely accepted. Finding any effective treatment is hard enough.

Instead, franchises attempt to replicate treatment through modeling and mentoring. Programs design step-by-step guidebooks to establish a new program while the program director or experienced clinicians train the employees at the new center. Sometimes, the director of the new center may actually move from the original center to start the new franchise. 

Eating disorder treatment remains long and hard without new scientific breakthroughs on the horizon. Expensive care for the chronically ill weighs heavily on the bottom line for health insurance companies so limiting care remains a cornerstone for minimizing financial outlay. This current system creates an underclass of people with chronic eating disorders and no way to find a path to recovery. A passionate group of directors of nationwide treatment centers can lobby government and insurance companies to offer adequate care for this languishing population. 

I see how noble this mission truly is. The rise in the incidence of eating disorders in recent decades, as I have chronicled extensively in this blog, is due to a combination of pressure for thinness, sedentary lifestyle, the rise of processed food and sanctioned starvation as a weight loss technique. But society has struggled to take responsibility for our self-inflicted epidemic.

Those unfortunate enough to have become ill labor for recovery in secret while everyone else marvels at what appears to be an incomprehensible illness. Making the suffering of these people public will hopefully force government and the health insurance industry to create fair and adequate treatment available to patients with eating disorders.

The parity for mental health care in the ACA and the increased potency of a centralized eating disorder treatment industry might just pack enough punch to make an impact.