Social Media: the New Forum for Eating Disorder Treatment

Medicine has largely neglected the care for people with eating disorders. Some hospitals across the country have doctors or even a small part of a ward dedicated to eating disorder treatment. However, the majority of eating disorder care occurs outside medical attention. Some psychiatrists or general physicians are involved when needed, but they are not central to treatment.

Psychologists focus more on eating disorder treatment and research. For the most part, psychology is interested in understanding the nature of people with eating disorders and assessing various treatment models for eating disorder care. This research has been much more helpful than medical research but remains limited in finding new directions for successful treatment.

For a set of illnesses vast in scope and still poorly understood and treated, eating disorders receive scant attention from traditional clinical models.

Social media created a new way for patients to come together and open up new ideas for care. People with eating disorders and other concomitant psychiatric and medical illnesses found each other online and began to establish a venue to discuss the overlap in various illnesses with eating disorders and even to hypothesize about the potential benefit for care.

Established academic institutions have started to follow up on these new concepts and research the connections between illnesses but without any clear and useful connection between diagnosis and new treatment yet.

For instance, ten years ago very few patients with an eating disorders and possible Attention Deficit Disorder would be prescribed a stimulant, such as Adderall, due to fears of appetite suppression and weight loss. Social media explored the connection between these two disorders which has led to a significant change in clinical care. Recent information and experience now show that treating ADD not only helps with attention but also eating disorder recovery.

This example is relevant in many other medical conditions: autism, Ehlers Danlos Syndrome and autoimmune diseases, to name a few.

Eating disorder treatment is now a collaboration between clinician and patient more than it has ever been. Treatment continues to be a journey down a murky path without clear indication how and where the next steps might lead. There are clues about what works best and how to move forward. Following the path blindly often leads to a dead end and failure, but using all tools at our disposal—social media trends high on that list—improves outcomes greatly.

The conundrum in eating disorder treatment lies in pretending any clinician knows the right path. A more experienced one will have information to help find the right direction, but an individual patient’s experience and the knowledge they find online are more important than ever to lead to true recovery. Treatment necessitates flexibility, openness and collaboration in order to be successful.

What are the Driving Forces in Eating Disorder Treatment

The discrepancy in the interest and knowledge about eating disorders between the medical field and laypeople is vast. Social media, memoirs and non-profit organizations meant to help people with eating disorders only continue to expand, in some ways even leading trends in research and treatment. Yet medicine remains quite ignorant and aloof with respect to the continuing epidemic in our society.

It’s clear why people want better treatment to be available. Anyone who has suffered with an eating disorder or seen a friend or family member with an eating disorder knows how destructive these illnesses can be. The ease with which one can communicate with new people and disseminate information through social media means that communities build and grow in all sorts of ways. These communities push for growth and access to treatment.

Medicine remains relatively uninvolved in the progress of eating disorder treatment. Medical students and residents still have limited exposure to eating disorders. Training in hospital settings or clinics rarely have experts on eating disorders available, so learning occurs in sporadic and disorganized ways. Doctors rarely finish training with a sense of how eating disorder care is different, both medically and psychologically.

The result is that people with eating disorders continue to have difficulty finding doctors able to understand how their bodies respond differently to being malnourished. The medical care is limited at best and often harmful.

People with eating disorders need to be careful about the doctors they see. Sometimes it’s better to see a doctor who is less knowledgeable but who at least won’t cause harm than to find a doctor who is aggressive but ignorant about eating disorders.

The line between adequate versus harmful care is tricky. Of course, eating disorders also cause medical issues which need to be addressed. I would never advocate for ignoring medical concerns. Instead, anybody with an eating disorder needs to do their best to discern how much a clinician knows about eating disorders before committing to medical care with that provider.

The needs of the eating disorder community have led to growth of treatment outside medical care. Virtual support programs run by clinicians and often people with more limited training is increasingly common. TikTok and YouTube influencers have become a means to consider different ways to understand eating disorders and limitations in available treatment. Reddit is now as much a clinical resource as any treatment provider.

The bigger question is what will come from such disparate and sometimes conflicting ways to find care for an eating disorder. The next post will address these discrepancies and some ideas of what’s to come.

Treating of Body Image Thoughts in Eating Disorder Recovery

Body image distortion is undoubtedly the must long lasting and difficult part of eating disorder recovery. The persistent negative thoughts about one’s body can last for a long time after normalizing eating patterns, fully healing physically and even finding new coping mechanisms for daily life.

Awareness of body image seems to have a specific pathway in the brain that involves both the visual and an emotional center. For people with eating disorders, body image thoughts often bypass the visual center and only involve the emotional center.

Theories about this difference in brain function imply that people with eating disorders perceive their body more through emotional brain center than visual ones even though they still perceive their own visual input as accurate.

Accordingly, people with eating disorders struggle even more to see their bodies as others do. Some clinicians call body image distortion a delusion, but I think this assessment is erroneous.

Instead, body image distortion appears to denote a connection between emotional centers and self-image that bypasses other brain centers which process visual information. The result is that people connect negative emotions and body automatically and subsequently attempt to change the negative emotions through eating disorder behaviors.

Treatment of body image thoughts abound. The behavioral approach focuses on exposure to one’s body in order to decrease the negative reaction. Psychodynamic therapy tries to separate negative thoughts from body image by spending time addressing and understanding the negative emotions. Other approaches include art therapy and hypnosis.

All of these treatment modalities can help, but the necessary component for improvement in body image symptoms is time. When someone in recovery eats in a consistent way and works towards finding new ways to cope with life instead of using the eating disorder, body image thoughts almost always subside.

The process takes time since it involves establishing new pathways in the brain to process and assess body image. The old pathway persists, but new thought patterns can supplant and sidestep the old negative thoughts and make body image thoughts much less distressing.

Whichever treatment works best for someone is likely the right approach. There is no right answer to help with body image thoughts. In addition, the clinician needs to stress continued work in recovery and patience that the thoughts will ease in time.

The Public and Private Loss in Eating Disorder Recovery

In the last post, I wrote about how people with eating disorders personify their illness. With the increased focus on mental health, especially for Gen Z, ownership or personification of a psychiatric disorder is increasingly common. People aren’t stressed any more but instead talk about my anxiety. My depression is the term used a lot more than I’m really sad.

The results of this change in language are both mundane and profound. Vocabulary changes through generations are to be expected and reflect both a desire for individuality and how cultural attitudes change.

The new terms to describe mental illness help shake off the stigma and enable more people to identify issues and get help much earlier in life. Fewer people will suffer for years untreated.

A different effect is that it is harder to give up or fully get better from a mental illness when the language used makes the disorder a part of one’s identity. It’s difficult to let go of an eating disorder fully when it becomes a part of how one sees oneself, how one navigates the world and even how one presents oneself to others.

Even though people don’t want to suffer, letting go of a critical piece of one’s identity is still a loss, and perhaps a choice.

This change is evident more in eating disorder treatment than anywhere. Eating disorders can become a large part of a person’s social media presence and an identifying factor to those around them. Although the goal of full recovery is paramount, an eating disorder in this climate can be so linked with oneself that, even after getting significantly better, announcing full recovery can be difficult.

Recovery needs to include a more direct approach to the loss of eating disorder as identity, not just in oneself as always, but also publicly. The stigma and shame around eating disorders very much still exists; however, the knowledge, exposure and understanding around these illnesses are all much more evident in younger generations.

Due to the substantial cultural change about mental health, eating disorder treatment can adapt to accommodate and acknowledge how recovery looks and feels different now. The loss of a piece of identity is private and public. Attention to both processes will help many younger people fully recover.

How the Therapy Relationship Helps People Leave Ed

Unlike any other psychiatric disorder, eating disorders are often personified. They are referred to by name, Ed, as a friend or as a partner.

The concept of having a relationship with one’s eating disorder is not just a turn of phrase or a therapy tool. Eating disorder thoughts and behaviors replace the many ways one might turn to family, a partner or friends for support, solace, guidance or comfort.

Eating disorders provide reliable, consistent and predictable answers to difficult situations. They provide rules and structure around food and body when life becomes challenging. They can be strict but caring when events in life get frightening. They can be calm and soothing for periods of enormous stress. And they can be punishing if one’s actions feel like too much to bear.

Ultimately, eating disorders aren’t just about the food, as the saying goes. The disorder provides a stable, steady relationship to help navigate the emotional and psychological challenges life brings.

Once anyone has that kind of support, no matter the associated burdens and pain, it’s very hard to give it up.

After recovery begins, one has to learn how to handle all the emotions and confusion that would automatically be buried under eating disorder thoughts and behaviors. These emotional steps are one of the hardest parts of recovery. Every emotion feels unbearable. The pressure of experiencing these feelings and not acting on them makes the emotions feel too large and overwhelming.

Trying to manage these feelings without any coping mechanisms is extremely challenging at first. Regular relationships in life often are not equipped to handle the initial bursts of emotion in recovery.

The therapy relationship is well equipped to handle all these emotions and thoughts. Recovery almost always needs a therapy relationship able to withstand, process and move through the intensity of emotion that bubbles up when someone chooses to face the feelings and not suppress them with the eating disorder.

The therapy relationship becomes a beacon of hope and promise towards a new way of living without the eating disorder.

The path of treatment is often complicated and intense. The feelings at times are very positive and warm and other times very angry and painful. If the therapy relationship can withstand all these feelings, the person has the opportunity to learn how to identify, express and manage their emotions in positive ways to foster relationships in their lives.

Therapy serves as a vehicle to help people safely learn how to see their emotions as part of their human experience, not something to avoid through the eating disorder. Doing so means the possibility of true recovery.

Metabolic Dysfunction in Eating Disorders

The term metabolism means different things in different settings, but a clear medical description is essential to understand eating disorder recovery.

The biological definition is the process through which the body utilitizes the food we eat both through energy expenditure and storage.

There are many factors that influence a person’s metabolism: genetics, age, lifestyle and exercise to name a few. Metabolism also can change in hours, say after a meal, over days to weeks like with increased exercise or over years through aging.

Metabolism regulation occurs largely through the gastrointestinal hormonal system that adjusts how energy is used. Other hormonal systems alter metabolism over longer periods of time as well.

Eating consistently regulates metabolism so that the body can rely on sufficient energy through food and then adjust metabolism as needed for external factors that change in the short-term.

Eating inconsistently, often irrespective of the body’s typical needs, stresses overall metabolism greatly. The body will to attempt to adjust the hormonal signals that affect metabolism due to these changes but struggles to do so effectively when eating is erratic, intermittent and completely unrelated to hunger.

The first step in eating disorder recovery involves consistent meals and snacks at fairly regular times through the day. The reason a meal plan is so important is to help the body return to stable metabolic function. Doing so helps re-establish homeostasis (overall stable biological functioning of the body) which is much less balanced during period of disordered eating.

The biological underpinnings of an eating disorder helps explain how disruptive these symptoms are. In this blog, I have written at length about the psychological and emotional effects of an eating disorder. Unlike other psychiatric disorders, eating disorders cause biological symptoms, specially metabolic, which stress the body immensely. It takes an enormous amount of effort for the body to maintain stability during long periods of disordered eating. Normal lab results during these times belies the truth of how much damage an eating disorder causes.

Metabolism is not a contest about whose is fast and slow. That definition reflects the weight bias in our culture and the ignorance about metabolic function. Instead, metabolism describes how our body manages energy intake and needs.

Understanding how eating disorders cause metabolic dysfunction is necessary to know how these disorders affect our health. Recovery needs to prioritize normalizing metabolism as a first step through regular eating.

The Rebuttal to “Why Can’t You Just Eat?”

People who don’t understand eating disorders always ask someone struggling with one a simple question: why can’t you just eat?

To people versed in these illnesses, let alone those who are struggling with one, the question is frustrating, upsetting and ignorant. Being asked the same question time and again becomes truly demoralizing.

However, the question comes from a simple and logical place. People without eating disorders just eat. Even if they worry about what they eat, when they eat or their body in general, the premise of whether or not to eat is never really relevant.

The biological imperative to eat is just too powerful.

Eating disorders, by definition, indicate a strong urge to eat or not eat by other factors then hunger and fullness. These behaviors become full-fledged eating disorders when disruptive enough to interfere greatly with daily functioning in life.

Many people think a lot about their food and body. Our culture continues to greatly magnify the importance of food and weight. Capitalism and the media prey on these communal fears, with Ozempic and the GLP-1 agonists being the latest corporate cash cow for our collective obsession with weight.

And the ever present drive towards thinness means no decrease in people developing eating disorders.

The answer to the question “why don’t you just eat” is both simple and complex.

The simple answer is that you have an eating disorder which means that you have other thoughts and urges that dictate when and how you eat. And so “just eating” isn’t possible.

The complex answer is connected to what treatment means. Recovery aims to regulate eating into a pattern based on hunger and fullness and less on the psychological and emotional drives of the eating disorder. The best step for most people is to eat according to a meal plan created by a professional and to relearn hunger and fullness cues. In time the goal is to “just eat” again but that comment isn’t helpful or kind with respect to eating disorders.

A more thoughtful and education about that overused question hopefully will lead to more understanding, and perhaps even more support, going forward.