When people learn that one of my specializations is eating disorders, they often ask me to explain why a person develops anorexia, bulimia or binge-eating disorder.  Many people just can't fathom how a basic physiological need can become so complicated and the source of so much internal conflict.  For some, the cure for an eating disorder seems obvious - anorexics just need to eat and over-eaters just need to stop eating!  "If only it were so easy!",  my patients and I respond.

The truth is that a person develops an eating disorder for more complicated reasons than you might expect, and there is not just one explanation that fits all people.  That said, I have noticed some common trends and issues that have helped me to understand why something as basic as eating can become so problematic.  I'll share some of my observations with you in this post. In a future post, I'll address some of the other factors (cultural, familial, etc.) that also may play a role.

First of all, it's important to understand that an eating disorder is not simply a body image issue nor is it really about food per se. Sure, people with eating disorders are often dissatisfied with their bodies (many think they are "too fat" or are obsessed with a particular part of their body that seems imperfect), and most think about food a great deal of the time (whether counting calories, burning calories, bingeing, cooking, etc.).  And to make matters even more complicated, lots of people would like to lose a bit of weight, and can even diet or exercise in a healthy way without developing an eating disorder. I think that the difference between those who struggle with an eating disorder and those who can diet and exercise without a problem reflects one’s ability to tolerate imperfections and other painful feelings like inadequacy and uncertainty.  No one enjoys those feelings, but if they’re unbearable, then one is  more vulnerable to developing an eating disorder or other form of addiction.  In other words, the symptoms that are associated with an eating disorder (like restricting, bingeing, purging, etc.) usually reflect anxiety about a myriad of feelings that can't be openly discussed or acknowledged. For many, just the feeling of needing something (food, comfort, support, etc.) feels shameful. This is why I emphasize that eating disorders are not really about food or trying to control one's weight. Eating disorders are about trying to gain a sense of control over one's life and emotions through controlling, and sometimes even punishing, one's body, or by using food as a source of comfort.

Let me elaborate this idea a bit further. An eating disorder is usually triggered by a crisis or event(s) that is subjectively experienced as overwhelming. It's important to underscore that the trigger can be something that many people would think of as minor, or as something that occurs in the course of normal life - like a breakup, or struggling to do well in a new class. I can’t underscore this enough - the experience is subjectively experienced as overwhelming.  Of course, an eating disorder can also be triggered by something that most of us would think of as overwhelming - like the death of a parent or a sibling. What matters is not whether it's objectively and universally seen as overwhelming; rather, it's the individual's perceptions that matter.

This event or experience, as minor as it might seem to someone from the outside, generates feelings and reactions that are overwhelming to the person who experiences them. In the case of a person who develops an eating disorder, he or she doesn't know how to manage and regulate these feelings. And when a person also sees such feelings as evidence of weakness, or being out of control, the picture becomes even more complicated - the feelings themselves evoke other feelings like shame and humiliation.  It’s also not unusual to believe that their feelings will burden others, so they hide their feelings from others and rely instead upon their symptoms (bingeing, restricting, over-exercising, etc.) to manage the feelings and anxiety, and unfortunately, this is often confirmed by others in the person’s relational world (more on this in a future post).  Whereas many people would gain support and comfort by sharing those feelings with friends or family, people with eating disorders more often feel ashamed of their feelings and needs.

Without another way of managing and regulating these overwhelming feelings, the body (and food) offers an avenue for dealing with the anxiety and pain. The focus shifts from the real source of pain to controlling and managing one's body and/or using food as a source of comfort and containment. The focus is diverted from emotions that make the person feel out of control and vulnerable, to a behavior that offers a reliable, physical outlet and distraction. This is why it's not as simple as gaining or losing weight. In fact, trying to gain or lose weight without addressing the underlying feelings will only overwhelm the person more. This is why sometimes an eating disorder can actually get worse in the beginning of treatment!

In my work with people who are suffering from eating disorders, I am as focused on identifying and understanding these underlying feelings, and helping the person to learn how to respond to their feelings, as I am on developing a healthy relationship with their bodies and food.  I am interested in helping people to reflect on the meaning of their problematic relationship with their bodies and with food.  It's not simply my goal that the person gains or loses weight, though of course this is a necessary part of the recovery process. Nor is it my goal to stop a person from restricting, bingeing, purging, or over-exercising, although these can be expected outcomes of addressing the underlying emotional issues and personal meanings. Rather, I help my patients to learn to listen to their bodies and emotions in a new and meaningful way - to hear and respond to the anxiety and pain differently. As we understand the origins of the symptoms and develop new strategies for responding to overwhelming feelings, we will also establish a healthier relationship with one's body and food.

Please feel free to post any comments or questions you may have after reading this summary, and I'll do my best to respond.  You may also email me privately through this site.

Also, if you or someone you love is suffering from an eating disorder, you might want to check out these websites:

• http://www.something-fishy.org/
  
• http://www.nationaleatingdisorders.org/
  
• http://www.anad.org/get-information/about-eating-disorders