Eating Disorders

            For twenty-five years, I worked as a psychotherapist specializing in eating disorders – bulimia, compulsive eating, anorexia, and some other patterns that aren’t in the diagnostic manual.

Paying attention to food and eating can be quite natural.   Most people have a normal healthy interest in tasty foods and in being nourished regularly. Many teenagers, as their bodies change, find that diet is one factor they can experiment with. And it is natural for a new mother, after giving birth, to try to restore her body to its familiar dimensions. Many people are reevaluating their food habits in light of recent discoveries about diet’s relationship to heart disease, cancer, and longevity – plus the headline topics of pesticides, animal diseases, and genetically modified foods.  So for many of us, diet is a lively topic of conversation.  Interest in food is not a cause for concern if it only takes the form of conversation or sensible exploration, if the physical health is robust, and if other aspects of the person’s life (such as work, relationships, and self-esteem) are satisfactory.

Yet concern with eating can go too far. Many people have eating problems which aren’t actual eating disorders.  They may spend a lot of time thinking about food and weight, dislike their bodies, and avoid social contact when they feel fat. Food and body size play a large role in their lives.

Even more problematic is an actual, diagnosable eating disorder. This is more than just a temporary fascination with food and weight or a moderate level of worry.  An eating disorder is a habitual practice of compulsive eating, or eating and throwing up, or overusing laxatives, or eating so little that the weight drops dangerously. There are rare medical reasons for a person to overeat or refuse food, but if no medical cause is found, the diagnosis of eating disorder may be made.

Eating disorders start in the mind with distorted ideas about body size or personal worries that get channeled into eating.  This does not mean that you or the person you care about is crazy.  It means you or she has attached inappropriate meanings to the business of nourishment. Certain biochemical changes involving neurotransmitters can then perpetuate these distorted perceptions. Hilde Bruch, who wrote the first and foremost books on eating disorders, called them “a misuse of the eating function to solve problems of living.” This is the best definition I know.

People with eating disorders use food to address emotional problems—loneliness, grief, anger, fear, or the task of planning a future.  With their gradually ballooning or wasting bodies, with rituals and obsessions, they are sending family and friends a message:

·        “Notice me.”

·        “I defy your ideas of beauty.”

·        “I hate myself.”

·        “Set firmer rules.”

·        “If I stay messed up, maybe Mom and Dad won’t fight so much.”

·        “If I’m thin, then will you love me?”

·        “If I’m fat, will you stop worrying that I may leave you for another man?”

·        “I don’t deserve to be happy.”

·        “I’m scared of growing up.”

·        “I’d rather die than do things your way.”

·        “I can’t cope.”

·        “I have no idea what I’m feeling.”

For the person obsessed with food, self-respect depends on how  “good” she has been today, or this week, or this month -- how successful she has been in restraining her eating. With one little slip, her self-esteem slides into an abyss.  There, her despair can only be relieved by the one consolation she knows: food.

One sufferer may believe the world will not accept her unless she is perfect—physically, mentally, and in every other way. Another may believe he did not deserve to get anything he really wanted; his first law is to control emotions at all times. If you can picture these states of mind, you can begin to relate to the internal battle going on inside your loved one, even if you can’t see it on the surface.

Like money, food is a currency that can be used for bad purposes as well as good ones.  For instance, a person may use eating not only for nutrition but also to pass the time, to punish the self or others, to procrastinate, or to keep people away. Many personal conflicts can be hidden behind these patterns.  Anger is a prime example.  In some families and cultures, anger is forbidden.  A child born into this family or culture learns to suppress anger.  Stuffing food down one’s throat is a powerful way to stuff down anger (or any other feeling), since you can’t speak or cry with your mouth full.  Self-esteem can be damaged by stuffing emotions in this way, but for some people it is safer than feeling anger at others.

Lack of assertiveness is another important issue that may be hidden behind unhealthy eating.  Many food-obsessed people feel they don’t deserve to ask directly for what they want.  Instead, they use indirect means: being nice, looking hopeful, hinting, earning it three times over, doing it all themselves. When people feel they can never do enough to redeem themselves in the eyes of a critical, hostile world, they become people-pleasers.  For example, some people with eating disorders choose careers such as nursing or teaching in which they are rewarded for being in a helping or pleasing role, offering to others the very things they need themselves.  Since pleasing people is so important to them, they have developed masks of apparent confidence behind which problems can lie hidden from friends, relatives, and even themselves.

Body image plays a part in eating problems. The person who feels that the solution to misery lies in attaining that perfect slim body will orient life toward achieving thinness, putting off everything else until he or he is thin enough.  Most of the eating disordered clients we have seen feel their bodies are unattractive, ugly, uncontrollable—their enemies.  This makes healthy eating difficult: why bother to take good care of something you hate?

Advertisements, television shows, and movies reveal our imperfections.  We are shown in full color how our thighs “should” look.  Our own bathing suits leave us exposed for the world to see and (we fear) to judge. Since the media show almost no women with less-than-perfect bodies, the illusion is given that “if you don’t look like this, you’re nobody.”  To figure-obsessed women, the identity itself is precarious, dependent on success in dieting, forfeited at the least transgression.

But not all eating disordered people are obsessed with their figures.  Some people began over- or undereating to cope with a loss or during an illness, and then found they couldn’t break the pattern.  Others have self-esteem or mood problems and turn to food to help regulate their moods.

Food obsession may involve not only self-hate but also loss of control, loss of body awareness, above-average spending on food or diet-related items, and dread of holidays or other special occasions.  Sadly, it can also divert energy and talent.  After examining her feelings in therapy for some time, one woman exclaimed, “Now that I’m overcoming this obsession, I can start working toward my bachelor’s degree again!”  Others have regained energy for sports, classes, relationships, and creativity.

Control is a central theme for people with eating disorders. To them, it is unthinkable to relax control over their thoughts, feelings, words, or actions. The fear is that if control is relaxed, even for an instant, disaster will follow. The illusion is that peace of mind can be purchased with eternal vigilance. The cruel trick is that the food-obsessed person gets the vigilance without the peace of mind.

Perfectionism is a characteristic of many bulimics, anorexics, and binge eaters.  They drive themselves to have excellent grades, the boss’s approval, the wittiest conversations and, of course, the perfect figure.  If they fall short of their expectations, they judge themselves harshly, shun praise, worry, and work too hard.  This perfectionism is not usually the love of doing a good job, but a driven fear of rejection.  Perfect behavior or performance seems to offer a route to some sort of acceptance.  Unfortunately, the perfectionist almost never gives herself full marks for a good job, since she is imagining an even more perfect performance.  So even success brings no praise or pleasure.  It is as if the eating disordered person must be perfect, but cannot be happy. 

But what is this perfectionism for? It may represent a hope that a perfect performance can be a substitute for herself, which she dislikes and distrusts.  It’s as if she says, “My schoolwork, my house, my mothering, my body are me. See and accept them.” However, even if the desired praise is forthcoming, it doesn’t really soothe the anxiety. The hurting, invisible person within who produces the perfect performance remains hidden, feeling unseen and still insufficient.  So, seeing no way out of this vicious circle, she tries even harder to be perfect.

Relationships with other people, instead of being restorative and supportive, often feel draining to those with eating disorders.  Those we have known are generally hungry for love and respect.  They meet the world from a position of high need and low self-esteem. They believe, I’m not okay, and I must hide this dreadful secret—cover it up with perfectionism, or earn love by niceness and taking care of people’s every wish.

This is a disadvantageous position from which to meet other people.  The eating disordered person thinks the other is busy judging her, and can just imagine what the other is saying.  So she tries hard to please.  But this hard work creates resentment—which must be hidden.  She feels imprisoned and isolated. The people in her world are cast as potential or actual critics:

·        the person who must be placated;

·        the person she is angry at (but doesn’t dare confront);

·        the enviable, successful one;

·        the authority figure such as a teacher or a beautiful model she is supposed to look like;

·        the friend who blithely takes up her time;

·        the person she is supposed to be rescuing;

·        men who are to be impressed, and men who are sexually threatening. 

There are very few people who are seen as nurturing and accepting, or less acceptable than the person herself.

      Her relationships with others are contaminated by her relationship with her body. This accompanies her like an unwelcome guest in every encounter.  She may feel that her body is not the one she intends to spend the rest of her life with: this is not her real body—so this meeting, this friendship, this connection or romance or opportunity, is not wholly real either.  At best, it is a dress rehearsal for when she becomes thin and perfect.

            These are some of the foremost reasons that food gets mixed up with hope, fear, self-esteem, and communication. If you’d like to see more, ask for a copy of my book How People Recover from Eating Disorders (co-authored with Jane Kaplan, Ph.D).

Childhood Obesity

In the last few years, a blizzard of articles and headlines has brought childhood obesity into public view. It’s a serious problem – 31% of kids under age 18 are overweight or at risk for becoming overweight. And kids don’t just “grow out of it”: among American adults, two thirds are overweight, half of these being frankly obese.  For adults, the medical costs of obesity (treating diabetes, cardiovascular disease, stroke, and cancer) amount to $70-100 billion in the  United States. The saddest part is that obesity causes so much suffering and can even shorten lives. One team of expert came to the shocking conclusion that obesity can mean that for the first time in our history, a generation of Americans will have shorter lives than their parents.

One of my graduate students, Kim Hiatt, did such a brilliant job of finding all the many causes of childhood obesity that we published a scientific paper about it. Yes, the causes are more than just overeating and underexercising. We asked ourselves WHY children overeat and underexercise, and found factors ranging range from depression to a lack of safe outdoor areas to play. Would you have guessed that lack of sleep contributes to obesity?  or cell phones? or the deals schools make to sell junk food on the school premises? We found literally dozens of causes. If you want to read our paper, go to http://www.jsbhs.org/9049.htm