In reality, even when a person wants to be rid of it, there is a lot keeping the eating disorder in place. It is a much more complex disorder than it seems to be. It may seem that the person is being stubborn in the name of vanity. What is actually happening is that food and weight have become tools to manage profound emotional pain. This is the key to understanding the person’s relationship with their eating disorder.
When a person’s relationship with food is used to manage emotional pain such that it causes significant physical, psychological, or emotional consequences, they have developed an eating disorder (ED). The emotional pain often involves feelings of low self-esteem or insecurity, depression, and/or anxiety. In many cases, the person hides the pain so well that it may not be visible to others.
In ways that I will try to illustrate below, the ED is used to help them tolerate that pain. In their mind, they have to maintain and protect the ED to continue getting relief from their pain. Protecting the ED often means spending less time with loved ones or anyone who might confront the ED. It often means not attending social events that have food. It might mean not going anywhere until they meet their daily exercise quota. They live a life dictated by the rules of their ED.
It is important to note here that if the person is medically malnourished, their judgment, decision-making capabilities, and ability to effectively use logic and other cognitive functions may be significantly impacted. They are also more likely to experience depression and anxiety. This is a physical status and can be reversed only by nourishment.
Researchers are still working to understand exactly how and why EDs occur. Clearly the blaring messages in our society about body size play a role (the Fiji study is foundational in this area). Interestingly, there may be neurotransmitters and brain structures related to the detection of hunger and satiety and to the feeling of reward some of us get when we eat that may be damaged or are not at typical levels in people who develop EDs.
We also know that genetics play a role: genes contribute to 50-80% of the risk for developing an ED. While there is no “eating disorder gene,” our genes do contribute to our personality traits, and there are some traits that seem to increase a person’s risk for developing an ED. These traits include being: anxious, risk-avoidant, sensitive, perfectionistic, compliant/people-pleasing, obsessive, and achievement-oriented.
A person with these traits who is in emotional pain and doesn’t have effective coping strategies looks for an answer to their pain and easily finds it. It is the “answer” that blares from most magazines, TV shows, people in our lives, and influencers: Being thin will improve your life! Being thin will make you more likeable!
Losing weight is clearly the answer. Because these folks are inherently obsessive and achievement-oriented, they tend to take whatever they do to the next level – from diet to anorexia, from overeating to bingeing, from focus to obsession. Their new focus on food and weight is more likely to get out of hand and become a disorder without them intending it or even noticing that it has gone that far.
Here is an example of one generic path to an ED: It begins with a person who is anxious, perfectionistic, a people-pleaser, and dissatisfied with her appearance. She begins college or a new job and worries about being judged by everyone. She stays awake night after night worrying whether she can do well in her classes or work tasks. She badly wants to be accepted, so she starts to diet. She creates a strict meal plan for herself and feels good when she follows it. She begins to lose weight.
After some time, she starts to feel better about herself because she is seeing a smaller body in the mirror and other people make positive comments about it. This soothes her general anxiety that people will reject her. She decreases her food intake further to speed up the results.
As an added bonus, eating less than everyone else becomes something she is good at, a “skill” she feels proud of. She begins to feel secretly superior to others for perhaps the first time in her life. For those who know the pain of low self-esteem, this is very powerful. Bonus #2: the focus on food planning and exercise routine promotes a sense of order and organization, keeping feelings of overwhelm at bay. Structure and organization also promote a sense of being in control.
All of these things – or any one of them – make her push herself past “reasonable” limits to keep going in spite of the negative consequences. She feels like she finally has the key to being accepted – by others and herself. She can feel emotionally safe as long as she can maintain this body size and discipline around food. Being as thin as she is and eating as little as she does has become the basis for her self-esteem and her identity.
There are infinite other paths to developing an ED. It can start with a particular relationship with food. For example, many people turn to food as a comfort. Overeating, like undereating, can be psychologically rewarding. It can be very comforting to know that the pain of feeling lonely, stressed, or angry can be dulled by zoning out and eating a gallon of ice cream. Bingeing on fast food from three different places every night after work might be the strategy that “works” for someone who is trying not to think about the abuse they endured. If you have no better way of coping with emotional pain, you might turn to food more and more often. It feels like a readily available, constant friend.
For a person who tends to be obsessive, making extensive rules and lists about food that must be triple checked every day can be extremely soothing. Structure feels good. It is also a way of creating a system to tell yourself whether you were “good” or “bad” that day. Many people don’t have an internal sense of their worth and look for external ways to gauge their worth. The way you do food (or, more often, the way you don’t do food) can be used to assure yourself that you are a good or worthy person.
To understand EDs, it is necessary to realize that the behaviors associated with EDs (e.g., eating very little, bingeing, purging, overexercising, focusing to an extreme degree on food and weight) become coping mechanisms. They help the person manage whatever stress or painful feelings they are living with at the moment in ways that may be hard to understand or even see. These behaviors feel absolutely necessary for getting through each day. To complicate things further, the person is often unaware of the connection between their food-related behaviors and their emotional pain. They themselves may not understand why the ED feels so necessary.
The person with the disorder feels like the ED is helping them. The people in their life are clear that it’s hurting them. They are focused on the negative consequences of the ED, which often include loss of relationships, loss of physical health, and loss of joy. It can be very hard to find any middle ground.
It helps tremendously to have some understanding. To appreciate the internal tug-of-war that may be happening, and the fear that comes with giving up a security blanket. The person with the ED needs to be assured that while they work on letting go of the ED, they are going to be shown other ways to manage life, someone is going to help them build healthier bases for self-esteem and identity, and that they are going to be loved through the process.
No one sets out to develop an eating disorder, but the behaviors can quickly become addictive and the person loses control over them. Professional treatment makes a difference, and it is important to begin as soon as possible. Research shows that the longer an eating disorder exists, the harder it is to treat.
Watch Catherine Pawley describe her experience with Anorexia.
Watch Susannah Laing describe her experience with Bulimia and recovery.
(Trigger warnings for both)