One thing I have had to learn to accept is that my patients will always outsmart me! Every person that I have worked with has been intelligent, compassionate and very very creative. All of that creativity and intelligence gets funneled into preserving the eating disorder behaviors. If you have a suspicion that a client is using food manipulation as a maladaptive coping skill, you are probably right!
I find myself educating families on the deeper nature of eating disorders because the common perception that eating disorders are about vanity and that if their loved one ‘would just eat everything would be fine.’ What is most important for clinicians to understand (and sometimes explain when loved ones are resistant to a step-up) is that eating disorder behaviors are a patients way of trying to cope with (avoid) intense uncomfortable emotions. Unfortunately, malnutrition is a very effective way to keep oneself emotionally numb. Being at a nutritional deficit, whether it is due to restriction, over-exercise, avoidance of specific food groups, or getting rid of food before it can be digested properly (purging or laxative use) changes the physiology of the brain. The limbic system and pre-frontal cortex both have significantly decreased activity, leading to a short-term experience of feeling ‘better’ with fewer racing thoughts. When this does not last, the brain is stuck in an addiction mindset of needing more (restriction, exercise, purging) to get the numb sensation back. Meeting restriction or exercise goals also give a sense of accomplishment with a high degree of control when it feels like one is failing or out of control in other areas of life.
Adding to the deception is the fact that eating disorders do not conform to society’s perception that one has to be emaciated to have a ‘real’ eating disorder. The physical and psychological effects of malnutrition can begin to occur even without any significant weight loss.
Eating Disorders often Mask Other Mental Health Illnesses
Eating disorders can originate from trauma, or your patient can have no trauma history. Eating disorders can function to manage depression, anxiety or Borderline traits or there may no other DSM diagnosis. That being said, it is very rare for me to have a patient with a ‘pure’ eating disorder. With the emotional numbing and structure that eating disorders provide patients (and sometimes providers) often view their behaviors as helpful or even necessary to counteract the symptoms of another issue. For example, being nutritionally compromised can keep the brain and body so focused on survival that PTSD flashbacks are suppressed or someone that is trying to avoid the crippling highs and lows of Bipolar disorder may find relief from the numbing effects of malnutrition. These ‘coping mechanisms’ do not maintain their effectiveness however and more of the behavior is needed to have the same suppression effects and eventually become unsustainable. Working on interrupting behaviors is a very scary and dangerous proposition for someone with an eating disorder because they quickly notice the apathy and hopelessness that comes with depression or the flurry of worried thoughts that come with anxiety or the relationship issues that come with borderline traits returning. It is very important as a private practice clinician to be prepared for seemingly new symptoms and issues arise with any attempts to interrupt behaviors and normalize this for your client.
Eating Disorders Change how the Brain Works
Working at one of the highest levels of care available for eating disorders has allowed me to witness first hand the impact malnutrition has on the brain. When my patients first arrive they often appear to be very logical and thoughtful, making arguments for why their treatment should be specialized (lower weight goal, exclusion of family, etc.) but the reality is that their pre-frontal cortex is not working at full capacity. When someone is malnourished their emotional reactions do not have the same filter and it becomes much more important to the person to ‘fix’ how they are feeling. Unfortunately, as discussed earlier ED behaviors are very effective at numbing emotions. My patients will talk about how much they care about how their behaviors are affecting loved ones, but in my experience, they are frequently unable to act in accordance with this value because of the limbic reactivity. The brain also gets caught up in almost obsessive-compulsive pathways that on the surface sound logical (“I feel better when I’m eating healthy”). What is different from a well-nourished brain is that the brain cannot deviate from this pathway, often spending 80 to 90% of their day running through these thoughts. The depth of the underlying fear is also different from a well-nourished brain; as an outpatient clinician, it is important to try to find out what else is under that logical statement. With the example provided above, I have found thoughts like “the only way I can feel okay is to eat perfectly,” “if I eat anything I consider ‘bad’ horrible things will happen to me” and “I have to eat the same or less than I did yesterday or I will gain weight and become morbidly obese.” You cannot talk someone out of these beliefs when they are malnourished in any way, the brain just does not have the resources to generate new, more flexible thought patterns. Luckily all the research shows
I am hoping that at this point you aren’t hearing me say “You just can’t treat eating disorders at an outpatient level of care.” I hope instead that you are feeling more aware of what to look for and that you are less likely to have a patient’s Eating Disorder fly under the radar untreated. Next week, I will share with you the resources that are available to you as a private practice clinician to support you as you treat your patients struggling with an eating disorder. I will also provide information that will be helpful for families and loved ones.