Just Eat: Questioning the Concept of ‘Choice’ in Eating Disorders

By Elizabeth Langreck, MS, RDN, Director of Nutrition at Promises ScottsdaleAnorexia nervosa, bulimia nervosa and binge eating disorder are life-altering, life-threatening psychological illnesses characterized by extreme eating habits and an obsession with body weight or shape. Eating disorders do not discriminate. Men and women of all ages, races, religions, sizes, education levels and socioeconomic classes are vulnerable.
Man Looking at Plate with Tiny Tomato

The tragic death of 26-year-old Max Briles belies one of the more common beliefs that eating disorders only affect females. Days before Briles, a "self-proclaimed anorexic," succumbed to the illness, he had treated himself to a few bits of cucumber, deserving the reward, he figured, for adhering to his strict diet. "It did seem to increase water weight, but it was totally worth it," the Madison, Wisconsin, man wrote in his journal on Oct. 6, 2016. A few days later, his parents found his body. He had refused to get treatment because he thought he'd be "the only guy," his mother said.

"It's so hard to suffer from (anorexia)," Max's mother Becky told the Associated Press. "It's prison for the person who has it." Becky once lived in that prison, having struggled with anorexia in middle school. It doesn't come as a surprise that mother and son would both suffer from an eating disorder. Research shows that up to 60% of an individual's risk for developing an eating disorder is due to genetic factors. What's more, eating disorders can strike at any age. A 2006 study published in the International Journal of Eating Disorders involving 1,000 women between the ages of 60 and 70 revealed that 60% of them were unhappy with their bodies and 80% were practicing some sort of weight control.

How Eating Disorders Start

The eating disorder comes together like a puzzle. The frame of the puzzle is made of genetic and biological pieces. What I've seen in practice is that a majority of my patients, if not all of them, have some degree of an anxiety or mood disorder, and certain personality traits or temperaments that make it difficult for them to experience, tolerate and/or regulate their emotions. Environmental and psychological pieces get added along the way. Some pieces are more significant, or more identifiable, than others, but all can contribute to the big picture — family systems issues, psychological trauma(s), major life changes or stressors, social messages, social media, fashion magazines and the diet industry — the list goes on and on.

Body image is aggressively pushed on the internet. Men and women of all ages are constantly bombarded with messages like, "look this way and you will be happy," "look this way and people will like or desire you," "this diet will fix your health and emotional issues," "you are a better person if you eat this food and not that food." In essence, we are told that, "it's not OK to be you." Images in advertisements and magazines are strategically manipulated and enhanced. Constant exposure to this results in unrealistic and unattainable body ideals that can alter the perception of self. A culture or society that idealizes the unrealistic and unattainable will perpetuate shame, fear and dividedness; and this is what feeds the eating disorder.

This also applies to the messages from the multibillion-dollar diet industry. Blatant and latent messages like: "Eat this, not that," "this food is good and that one is bad," "you're bad if you eat that." Nutrition science is a relatively new science, and the internet and social media are flooded with poor quality nutrition articles and recommendations that have not been studied or peer-reviewed. This barrage is dangerous at the time when an individual is developing their relationship with food.

What Does an Eating Disorder Look Like in Real Life?

Here is a frequent scenario I've seen:

Let's say the parents of the eating disorder patient have tried fad diet after fad diet — low-fat diet, low-carb diet, gluten-free and dairy free diet, etc., and let's say these parents frequently verbalize how unhappy they are with their bodies and weight. A hypersensitive child with genetic loading for an eating disorder or anxiety disorder may pick up on these behaviors and internalize them as to how they should eat or perceive their body.

Let's combine parental dieting and poor body image modeling with abnormal exercise habits, body-shaming among members of the family system, self-righteous eating and food-shaming. Then, the straw that breaks the camel's back:  the child experiences a life trauma — loss of a loved one or pet, being bullied or shamed at school, a major life transition, sexual abuse, puberty, etc. All of this ends up swirling around in the child's head, and he or she does not know what to do with it.

To manage the distress, the hypersensitive child may take the habits and behaviors learned in the family system to the extreme. Controlling food and the body turns into a coping strategy to manage the stress or anxieties of life. When this strategy gets taken too far, the physical, mental, emotional and social health of the child is destroyed, leaving a body and brain traumatized by malnutrition, a psyche traumatized by paralyzing guilt, anxiety, fear, shame and isolation.

Emotion-Focused Eating

In short, the eating disorder can be a conscious or unconscious way to cope with emotion and difficult life experiences. The behaviors used in the eating disorder tell a story of what emotions the person is experiencing internally.

I've worked with many children and adolescents who have unconsciously controlled their family systems with extreme eating habits. A frequent scenario I've worked with is divorce. Mom and Dad decide to end their marriage, and this turns the child's life upside down. Physically overwhelmed by anxiety, fear and grief, the child loses his or her appetite. Sudden weight loss in children is dangerous and requires immediate attention. This forces the parents to work together, such as arranging treatment, visiting the hospital or attending therapy sessions. Again, this isn't necessarily a conscious choice by the child. The child is just doing whatever they can to manage their internal environment by affecting their external environment (via eating disorder behaviors).

Conscious development of an eating disorder might start as an innocent attempt to change eating habits for health or ethical reasons, for example, eating only organic food or becoming vegetarian. But for the individual with the genetic and biological loading, this attempt is taken to the extreme. Food variety and quantity become so limited that it disturbs the individual's health. The rigidity of "when, what and how will I eat" is debilitating and behaviors become unstoppable compulsions. The individual becomes a slave to the eating disorder.

Co-Occurring Disorders

The nourished brain has a choice, but the malnourished brain is robbed of choice. When the human brain is malnourished, the individual's rational decision-making skills and impulse control are cruelly impaired.

Anxiety, depression and other mood disorders co-occur quite frequently with eating disorders. It becomes the age-old question: "Which came first, the chicken or the egg?" Many times the eating disorder develops as an attempt to manage an anxiety or mood disorder. For example, if a patient is depressed, controlling food is a distraction from feeling depressed. The kind of constant planning seen with eating disorders occupies the brain. Put simply, negative feelings are avoided by choosing something else to think about or do. Since we need food several times daily and we live in our bodies every moment of our lives, there is a constant thought or object to be distracted by.

Other psychiatric conditions we commonly see with our eating disorder patients are obsessive compulsive disorder, post-traumatic stress disorder and substance abuse (research tells us that about 50% of people with an eating disorder abuse alcohol or other drugs).

What People Don't Understand About Eating Disorders

"Just eat" is the common phrase I hear family members say to the sufferer. Another misconception is that the sufferer has a choice to "just eat." However, genetics, brain biology and malnutrition all overrule this choice.

The nourished brain has a choice, but the malnourished brain is robbed of choice. When the human brain is malnourished, the individual's rational decision-making skills and impulse control are cruelly impaired. Eating breakfast or taking one bite of food is such an overwhelming task that unconscious and impulsive eating disorder behaviors take over to comfort the sufferer. There is no perceived choice for the malnourished brain, and this is the eating disorder victim's harsh reality, possibly contributing to the fact that eating disorders have the highest death rate of any mental health disorder.

Malnutrition changes the form of the brain and alters its circuitry. This results in abnormal firing in the parts of the brain that regulate mood, emotions, perceptions, rational thinking and executive functioning. Until the individual is rehabilitated with adequate nutrition (this could mean weight restoration and/or proper hydration and electrolyte balance) and abstinent from eating disorder behaviors, the brain is still at risk. Therefore, choice is impaired. Only after the brain is healed with nutrition rehabilitation does it have the ability to learn to make better thoughts and choices.

Eating Disorder Treatment

Treating a patient with an eating disorder requires compassion, empathy and patience. Trust must be cultivated and nurtured. Giving the patient structure and consistency is a must.

The relationship the individual has with the dietitian can be very challenging, as the dietitian is often viewed as a threat to the eating disorder. This is simply because it is the job of the dietitian to provide the client with the one thing he or she fears the most — food.

My role as a dietitian is to use food and nutrition to heal the body and brain from the trauma of the eating disorder, educate the patient on the health consequences of the eating disorder and abnormal eating habits, and help teach normalized eating. My goal is to help men and women improve their quality of life by improving their relationship with food and their body. Treatment for an eating disorder requires management from an interdisciplinary treatment team that includes a medical doctor, psychiatrist, registered dietitian and therapist. Each client requires a different degree of care from each provider.

When it comes to psychotherapy, Promises Scottsdale blends a variety of therapeutic methods to meet the needs of the client.

  • Cognitive behavioral therapy (CBT) is the number-one researched therapy model for eating disorders. With this approach, the patient is taught to question and challenge the thoughts and beliefs that support the eating disorder.
  • Exposure response prevention (ERP), a form of CBT, is at the core of eating disorder treatment. Briefly, the client is exposed to his or her fear and coached and supported to face the fear, while refraining from using eating disorder behaviors. Fear within the eating disorder can include fear of food, weight changes, changes to the body and irrational fears of the unknown.
  • Dialectical behavior therapy (DBT) teaches mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance, and frequently is used with bulimia and binge eating clients. DBT blends principles of Western psychological traditions and Eastern meditative traditions.
  • Eye Movement Desensitization and Reprocessing (EMDR) is a form of trauma therapy that we have seen very good results with. EMDR helps individuals address specific life events that have caused traumatic distress with the aim of neutralizing their emotional and physiological reaction to the recollection of the events. What I have seen in practice is that if a traumatic event has triggered the start of an eating disorder, neutralizing the emotional and physiological response to the traumatic event decreases the trigger or urges to use eating disorder behaviors. What I have learned from therapists on the treatment team is that EMDR engages similar brain mechanisms as those involved in the rapid eye movement (REM) phase of sleep, which activates the brain's information-processing system. This allows the individual to process the memory and traumatizing emotions. We generally use EMDR with clients who 1) are approved by the therapist as appropriate for this treatment (clients must have some grounding and emotion regulation skills), and 2) are approved by the medical doctor and dietitian as appropriately nourished as this can be a taxing experience for the brain and body, and we want the client close to full capacity before we challenge them.
  • Somatic Experiencing is also helpful in treating eating disorders. The eating disorder patient's mind, body and spirit are disconnected. Much time is spent in the mind engaging in obsessive thinking and avoiding sensations happening in the body. Somatic Experiencing is a body-oriented approach that is based on the stress responses of wild animals. It was developed by Peter Levine, PhD, who writes in his book Waking the Tiger, "Trauma puts the primitive brain into a state of constant activation. The results are impulsive, automatic reactions, which alternate between frenzy, withdrawals, and immobility/paralysis." The theory behind Somatic Experiencing is that trauma is not about the event itself, but rather the body's response to the trauma. In fact, the word somatic comes from the Greek word "soma," which means "body."  Unlike other forms of therapy that target emotional experiences, Somatic Experiencing focuses on internal sensations. Guided by a therapist, the patient gradually releases the pent-up fight-or-flight energy from the body, thus addressing the underlying cause of the trauma symptoms.
  • Psychodrama is also great for eating disorder patients because if they're malnourished, the cognitive piece — their thinking, their ability to form abstract thoughts, to rationalize — is compromised because the brain is not firing at capacity. Through role-playing in psychodrama, the patient gets to see and experience the metaphor for their life played out right in front of them. It's very easy to grasp. Psychodrama helps them see themselves and their experiences from an outside perspective. They can see in a physical form how they have maybe pushed family or favorite activities away, and pulled the eating disorder closer to them. It helps them work through family system issues and other relational and big events or traumas that may be playing into their eating disorder.

We also engage clients in expressive therapies like art and music therapy, and movement therapy such as yoga.

In many cases, treatment for an eating disorder begins at the inpatient level of care — the hospital. A cloud of denial surrounding the severity of the sickness coupled with fear often keeps eating disorder clients from getting the help they need.

The good news is that eating disorders are highly treatable and recovery is possible. But without treatment, about 20% of individuals with serious eating disorders will die.

Anyone suffering with the illness should know that it's OK to open up and be vulnerable. It's OK to be who you are. Having the courage to say "I have a problem" is not only the first step to getting better, it creates awareness and opens the door for more people to come together and talk about their own issues. Be the one to start that conversation.

Posted on March 2nd, 2017

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