This is a topic with which I am very familiar. During the five-and-a-half years I worked at a private psychiatric hospital, I spent about a year working with women suffering from eating disorders (in this setting there happened to be only women, even though it effects men as well). I helped monitor their food intake, did both one-on-one and group counseling, and helped monitor certain physiological functions.
This is a life-threatening disease that unfortunately has not received enough support. To start off, let us first explain what eating disorders are. An eating disorder, according to NEDA (eating disorder definitions)is either anorexia, in which the person severely restricts their food intake, or bulimia, in which the person eliminates the food after eating either by regurgitation or using laxatives to hasten bowel elimination. Some also consider binge eating an eating disorder as well.
There are some frightening statistics about the prevalence and consequences of eating disorders (Eating Disorder Statistics). According to the National Eating Disorder Association, it is estimated that ten million women and one million men struggle with eating disorders. Anorexia has the highest premature fatality rate for any mental illness. There is a certain shame with having an eating disorder hence not a lot of victims seek professional help. There is also, at least until recently, been a culture of thinness. Probably the most famous case of an eating disorder death was Karen Carpenter, a singer who died in 1983 of anorexia.
Eating disorders are more than just a mental health issue; they are life-threatening. We human beings eat because we need the nutrients in the food to sustain our bodily functions. Without those nutrients, our bodies starve to death. When we engage in activity, our bodies use food for fuel; we use nutrients as building blocks to keep our muscles and bones strong; and we use nutrients for the electrolytes that help our nervous system function and for our body to carry out its biological processes.
When the body is deprived of these nutrients, the body actually starts feeding on itself. First it starts to slow down so as conserve what it does have. Then, it starts raiding its own muscles for protein, even feeding off the heart muscle. Ultimately, the victim may die of heart failure because there’s just not enough heart muscle to pump the blood.
Many people have heard of a “5150”, made famous as the title of Van Halen’s rock album released in 1986. This is the code section that allows a law enforcement officer or mental health professional to involuntarily hold an individual in a psychiatric facility for 72 hours. The criteria for such an action are that the individual is either a danger to themselves, a danger to others, or gravely disabled. This code was developed back in the early 1900’s for—you guessed it—a girl who refused to eat.
As you might imagine, eating disorders are not about food; they are about appearance. In fact, they are not even about appearance. They are about self-esteem. Someone who controls their food intake to look a certain way does so because they feel that is the only way they will be loved and accepted. People see certain people on magazine covers who are very thin, but greatly admired.
People who have an eating disorder feel that the only way they will be loved is if they look beautiful and be accepted. In a very real sense, they are selling themselves for love by creating a look. Unfortunately, they are never perfect enough. There is an altered body perception. When someone with an eating disorder (bulimia or anorexia nervosa) looks in the mirror, they see a fat person. One of the methods we used to help them was to show them reality. We would have them lay down on a big piece of paper and outline their body. Many times, this didn’t work because even though their eyes saw the shape, their brains didn’t believe it.
Someone who has an eating disorder doesn’t believe they are entitled to love just because. We talk about unconditional love, that is, I love you for you, I love you for who you are, not what you are. People with eating disorders feel that they have to earn that love in order to be entitled to it. Therefore, they have to present a perfect appearance. This is a conundrum. If I don’t feel good about myself, then I’m not entitled to love.
Consider some ideas about what an eating disorder really is. Since the reality of seeing the actual body doesn’t change the perception of what it really looks like—i.e. fat, skinny or appropriate—then it’s not really about the body. It’s really about how the individual feels about themselves, then seeing the physical form of that. In other words, if I don’t like myself, don’t feel that others will like me for who I am and don’t deserve love, I’m going to see a “flawed” person. Nothing that I am physically is going make anyone else like me since I really don’t.
Many people have issues with self-esteem, how we feel ourselves. Different people express it differently depending on genetics and experience, nature and nurture. People who are anorexic have this thing about control; they are wound too tight. They are afraid that their world is too chaotic and this is how they control it. One woman I knew on the eating disorder treatment team was anorexic. She had a very chaotic family life in which they fought a lot. By restricting her food intake, she shifted the attention from the family problems to her illness. Now the attention revolved around her instead of fighting. This was not an attempt to get attention, this was rather a combination of her desire to control the family dynamic and express her feelings about living in a dysfunctional family. It was her way of acting out, expressing her anger, dysfunctional as it was.
Consider that there is an emotional link between food and feelings. If we’re stressed, one of the ways we feel better is to eat. Many of us have our “comfort foods”. People who binge eat may be seeking emotional comfort through food. If positive feelings like love won’t fill you up emotionally, then the food will fill you up physically as a substitute. If this anorexic woman wasn’t feeling the love in her family, then she was acting out by not eating al all, in effect punishing them by telling them she didn’t want their love. She was also punishing herself.
The problem too is that the eating behavior becomes a compulsion and it’s hard to stop. There are 12-step programs, modeled after Alcoholics Anonymous, for eating disorders. Consider that an eating disorder is not an addiction since there’s really nothing to which to be addicted. Rather, it’s a behavior that once started, stimulates the brain and thus becomes something that has to be done for the person to feel good, like excessive cleaning. That is not to say that they shouldn’t try the 12-step; whatever works.
People who are bulimia will eat and then purge the food either orally or anally. This eating behavior makes an interesting metaphor with our paradigm for emotions. A person wants love, but once having it, doesn’t feel worthy and rejects it.
As far as personality types go, I have found a distinct difference in bulimia and anorexia. The former tend to be more outgoing, high achievers and anxious to please. The latter tend to be more “anal”, needing everything in its place, things being a certain way. Binge eaters tend to be more depressed and withdrawn.
Eating disorder recovery is challenging. The primary focus, because of the insult to the body, is to make sure they are getting the right nutrients. Some people who are severe in their eating disorder will need intravenous solutions as the first step in the intervention. Nutritional supplements are a must. Those that are eating need to be supervised for as long as three hours after eating a meal to make sure that they don’t purge, and that there’s been plenty of time for the body to digest the food. The meals need to be very innocuous and benign so as not to cause additional stress; these people are having a hard enough time actually eating so they need to have it as pleasant as possible.
Psychologically they will need lots of support. They need to address their issues while their bodies are getting healthier. As always, helping them improve their self-esteem is key. We had pretty good success having some of them keep a journal in which they could write out their thoughts and feelings on a daily basis without any type of judgment.
Since an eating disorder can be a very insidious process of suicide, it is a syndrome that needs more attention. The shame needs to be removed. Some celebrities have famously and bravely gone public about their past struggles and this has inspired others to seek help who wouldn’t otherwise have done so. Also by going public, they have focused attention on this and helped reduce the shame of these disorders.
Perhaps soon with all this effort, eating disorders will be a thing of the past.
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