Anorexia: Are you Literally Dying to Feel in Control or Accepted?
What psychology is at play in the eating disorder anorexia nervosa?
A new movie called “To the Bone” starring Lily Collins seems to support the theory, somewhat tangentially, that anorexia involves a psychology of wanting to feel in control and accepted. As the anorexic starves herself, she overcomes temptation and achieves rigid control over her food intake. An anorexic who demonstrates an extreme degree of thinness is essentially initiated into a special club of other anorexics where they feel like they belong. This pro-anorexia, or “pro-ana” community is thriving online, where anorexics visit “thinspo” websites and get “thinspiration” from each other to continue their dysfunctional starvation diets.
The cost of this starvation or disordered eating in order to feel a sense of belonging or to gain a sense of control can be deadly. Let’s take a closer look at why anorexics might embark on a journey of starvation, and why helping an anorexic recover is possible, but challenging.
How Anorexia Begins: Body Envy … Among Other Things
According to some experts, in this age of Instagram and social media, something as simple as viewing pictures of other females with gaps between their thighs in their skin-tight jeans might be enough to encourage a person on the path of anorexia. Girls and young women of today envy and idolize skinny media mavens (i.e., supermodels, YouTube celebrities), and will go on strict diets in order to be more like them. But anorexia is more complicated than pursuing the simple goal of getting thin to feel more accepted in a society that idealizes fashionable, skinny girls. Anorexia is entangled with issues of self-esteem and self-control.
The DSM-5, or the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) from the American Psychiatric Association, lists the following symptoms as criteria for making a clinical diagnosis of anorexia nervosa:
- Persistent restriction of energy (calorie) intake leading to significantly low body weight (according to what is expected for age, sex, developmental and physical health).
- An intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even if already at significantly low weight).
- Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
While these criteria help to diagnose anorexia, they seem to fall short of describing the complex internal psychology at play in many people with this eating disorder. For example, an anorexic is likely to feel hungry all the time and to be a “foodie” who actually loves to eat and has intense cravings. Yet, it is the resistance to these cravings and the willpower to overcome the physical sensation of hunger that gives an anorexic a sense of accomplishment and control — despite the endless barrage of food advertisements and other external cues to eat.
Further, stress and trauma can be triggers for an anorexic. During or after periods of stress, anorexics often feel the need to exert even more control over their eating patterns or reduce a particularly troublesome feature of their body even more in order to regain a sense of equilibrium.
The issue of perfecting something and being in control — even if it is just perfect control of food intake and body size through compulsive calorie counting and exercise — in order to feel that all is right with the world despite its chaos is probably the driving force for most anorexics. And the concept that staying in control and maintaining perfect discipline over one’s eating and body is a positive, valid pursuit can make providing effective care for people with anorexia particularly challenging. Disrupting and reprogramming this way of thinking is often necessary.
Why Caring for People With Anorexia Is Challenging
Getting an anorexic into care may be half the battle to recovery. An Australian study of young women with anorexia found that this form of disordered eating is often seen as a healthy endeavor by the people who practice it. Because they justify and rationalize their restricted eating as healthy self-care, anorexics are reluctant to seek formal treatment for something they don’t view as a disorder or illness. With this “healthy anorexia” perspective, an anorexic’s logic might be, “Why would I seek medical care if I am already following a healthy diet where I eat only natural, pure foods low in fats and sugars?” This way of thinking can make it difficult for an anorexic to perceive that they are unhealthy enough to need help or that their body requires more calories (energy) to thrive. Compounding the problem is the popularity of “pro-ana” websites, anorexic fashion images and YouTube videos that reinforce the positive aspects of maintaining a super-thin physique.
The pathology around severely restricting food intake in the name of health has led to the recognition of a similar type of disordered eating called orthorexia nervosa, which refers to people who engage in extremely restricted diets for health reasons. Orthorexia focuses on the quality and type of food being consumed, rather than on the calories. Examples of orthorexia might include a strict gluten-free, dairy-free diet, or vegan diet. Orthorexia is considered a disordered pattern of eating that, like anorexia nervosa, can lead to malnutrition. This disordered approach to food is supported by marketing trends that promote “gluten-free” or otherwise restricted foods and menus.
In today’s food marketing climate, following a diet that only allows consuming foods in certain ways or in restricted categories such as non-GMO, organic, plant-based, gluten-free, low-carb or zero-carb and paleo, among others, is viewed as entirely “normal.” Countless diet books, clubs, websites and Facebook pages have cropped up in recent years, supporting the notion that trimmer is better, and that by following a certain diet to achieve a reduced body weight you can become part of a community that is collectively eating this way.
Recovery From Anorexia Is Possible With Multifaceted Care
In the women’s eating disorder program at Promises Scottsdale, clients benefit from a multilayered, multifaceted treatment approach that addresses eating disorders at several levels. Each client’s treatment plan is individualized to meet their specific needs. The idea is to uncover and treat the underlying causes and drivers of the eating disorder through a range of trauma-based therapies, including: individual, group and family therapy; nutrition counseling; psychiatric care; dialectical behavior therapy (DBT); trauma-focused counseling; body image counseling; eating disorder support groups, and mindfulness training and other mind/body holistic practices. Experiential therapies such as trauma-based psychodrama, equine therapy, music and movement, among others, are also included as an important aspect of the program.
“We have found that clients in our program are able to become nutritionally restored in a safe and supportive environment, and are able to address the underlying issues and trauma that led them to their eating disorder as a maladaptive coping mechanism,” says Shannon McQuaid, LMFT, LISAC, CDWF, CSAT, executive director at Promises Scottsdale. “Once they are nutritionally restored, clients also learn coping tools and supports for their continued recovery.”
McQuaid notes that many clients with eating disorders respond more effectively to the experiential therapies that are used in the Promises Scottsdale program. “This may be due to the fact that the brain can analyze and guard emotions in most situations, whereas experiential therapies release the emotion and trauma in the body without the logical mind jumping in to guard or protect.”
McQuaid has found that women in the program will have a dramatic shift after completing their psychodrama and experiencing their pain and hurt experientially. These therapies will uncover missing pieces to their eating disorder. McQuaid explains that this is significant because a person cannot change or address issues and struggles they are not aware affect them. She says that Eye Movement Desensitization and Reprocessing (EMDR) may also be used to help clients address trauma that is unveiled.
Clients at Promises Scottsdale also learn the role society plays in how women feel about their bodies. They learn the powerful messages about body image and shame we experience as women. These lessons are facilitated through body image experientials, and through sessions focused on shame resiliency and empowerment through the Daring Way curriculum. These sessions help clients deal with comparison and not feeling they are enough.
“These sessions are particularly exciting because you can see the lightbulbs go on when clients realize they are not alone and there is an alternative way to live,” says McQuaid.