At the "root" of an eating disorder

In my Twitter timeline this afternoon (you do follow ED Bites on Twitter, don't you?), I read the following tweet from the magazine Psychiatric Times, by way of The Canyon treatment center.

Trauma, rage, depression, codependency other issues may be at the root of most eating disorders.

The tweet linked to this article here: Eating Disorders' Underlying Issues.

I'll admit that any PR article has my journalist's bullshit radar on high alert. Remember, a press release is trying to sell you something--in this case, a treatment center, but they can also be selling a viewpoint, product, or idea. But press releases aren't going anywhere, and if you take them with a grain of salt, you'll usually do okay.

What made me twitchy was the use of the words "underlying issues" and about stuff being at the "root" of eating disorders. It's not that I don't think pre-existing and co-morbid conditions are irrelevant to eating disorders--far from it. They absolutely play into how and why someone might stumble into an eating disorder and then stay there.

But that doesn't mean that these issues are an "underlying cause." At the root of an eating disorder is an eating disorder. For whatever reason, a person with an eating disorder processes information about food, eating, exercise, and often weight in a very different way. To them, starvation may anesthetize anxiety or depression. Or maybe binge eating and purging helps alleviate social discomfort. If this didn't happen, you wouldn't have an eating disorder.

I'm not against addressing underlying disorders--much of the work I'm doing now is to address my anxiety issues. This untamed anxiety really drove my eating disorder. Starving and overexercising gave me relief. But addressing these "underlying issues" without first addressing the eating disorder is like trying to fill a bucket with a large hole in the side. It's kind of futile.

Refeeding alone isn't enough. Sitting someone with an eating disorder in front of a plate of food and just saying eat isn't enough. ED'd people need lots of support. Remember, the eating disorder does have some perceived benefits. Saying "Go home and eat a sandwich" isn't going to cut it. But a crucial part of treatment involves getting over your fears of eating that sandwich.

I always resented people digging through the midden heap of my life, looking for the "root cause" of my anorexia. The rage I had was primarily starvation-induced (even the men in Key's Starvation Study had anger outbursts). I didn't have any traumas, and therefore I figured I couldn't really be sick because I didn't have a reason to be. And so I spent years trying to find a cause to my eating disorder to the almost complete exclusion of addressing my actual illness.

If you have a tumor, you don't want to begin treatment until you figured out the underlying cause for your cancer. This isn't to say that it's not important to take a good look at your environment and remove any carcinogens, but that's not a reason to delay treatment.

I'm not saying that issues of trauma, bullying, depression, etc, shouldn't be addressed in treatment. In fact, I think they must be addressed to ensure full recovery. But that's not the same as saying that these things are an "underlying cause" of an eating disorder.

21 comments:

K-pedia said...

Thank you! At my treatment center, all of these girls had sexual trauma, violence, kidnapping, all kinds of dramatic episodes in their past ... and here I was, with mild clinical depression, an ED, and no explanation for either. I felt like a fraud, like I didn't "deserve" my ED, or I wasn't really sick enough. I had to stop going to group because I was so negatively affected by these emotions.

Of course there are comorbid or interacting factors that contribute to the intensity or manifestation of an ED, but I can't point to a single thing that caused me to be bulimic ... it was just the best coping mechanism I could find at the time. End of story.

It's nice to hear someone else with that same personal history.

Jade said...

I couldn't agree more!!! There doesn't always have to be this hidden issue. I remember when I was hospitalized and the doctor that came to talk to me was like, "have you been molested?" no... "Have you been using drugs?" no.... "Are your parents divorced?" no... "Do you hate your mother?" no....
I was just a girl with an eating disorder and it was so hard for the "doctors" to understand that...

James Clayton said...
This comment has been removed by the author.
anorexiaoni said...

This is really interesting and raises an important point. It's also pretty bizarre in that I feel I'm always up against the perception that eating disorders are all about food issues - the deeper roots get overlooked, which is the opposite of what's being said here.

It's crucial to remember that EDs build themselves on a lot of different things and that comorbid conditions contribute, as you all say. In my own case I can trace underlying factors that predate and preceded anorexia and eating disordered behaviour. That's no true for everyone though.

The crucial truth about EDs is that each sufferer is an individual and that broadstroke methods and treatment aren't going to work. Interesting post and the reminder and perspective

Rose said...

Carrie- unless i'm understanding you incorrectly, i think you might have a couple of typos here:
" It's not that I don't think pre-existing and co-morbid conditions are irrelevant to eating disorders--far from it." Did you mean to leave out the "Don't?"

and
"If you have a tumor, you don't want to begin treatment until you figured out the underlying cause for your cancer"

Did you mean "you don't want to NOT begin treatment" ?
otherwise i think this is a GREAT post, i agree 100%. It drives me CRAZY when treatment professionals try to figure out the underlying causes of an eating disorder while someone is still actively symptomatic. I had a therapist a few years back who was like this, and it just was a waste of a year (and lots of money)
oh, if i'm just misunderstanding your about the typos i apologize.
:)

Carrie Arnold said...

Rose,

Yes, you're right. Those are typos. :)

James,

EDs aren't just "food issues." Not at all. And there are often underlying disorders/concerns/issues that extend far beyond the food piece. Addressing eating alone isn't sufficient for recovery.

But I just don't like how the automatic assumption is that the eating disorder is a sign of how messed up you and your life are. EDs usually come with "friends," aka co-occurring conditions such as addiction, depression, anxiety, ADHD, etc. I think the ED is often how people who have these other conditions and are genetically predisposed to an ED try to self-medicate. Not addressing the ED during treatment, though, is a big mistake (the idea being that you treat the other conditions and the ED will go away).

Angela E. Gambrel Lackey said...

At this point, I don't care what caused me to develop anorexia — I just want to recover and I don't want to wait until I find out the cause(s). I'll use the analogy my doctor uses all the time: if we were sitting in the office and it suddenly caught on fire, would we first question what started the fire or else save ourselves?

It's not that I don't think past history isn't important. I know I have past trauma issues, some that I can't remember. So what? Am I going to spend the rest of my life dragging myself through the pain of the past or am I going to move on, eat and get healthy and live? Imo, too much energy can be wasted on trying to find "root causes." I'm working on finding solutions to help me live my life. I am so ready!

Anonymous said...

Great post. As a patient, I was always envious of those who weren't "saddled" with my issues. Those who didn't have to go to trauma group and cry, those who had supportive families and hadn't had what I felt experienced pain or "enough" pain.

It was stressed that at that time that our stresses were relative, a concept that I wholeheartedly embrace today. Recovery has given me that.

To those who don't see underlying issues "other than society," I often think of other diseases like cancer. There are cancers of unknown primary origin. So I guess we can chalk it up to the same thing. Why go dig?

The only reason to search is to keep it from being an impediment in the future. But no need for an active search if all is well. There is need to keep an eye out and to be self aware.

Matt Joseph said...

I agree with you on this, Carrie. The eating disorder itself is the root. The symptoms are whatever results from the eating disorder. Getting rid of the eating disorder itself should be the primary objective, which will then do away with the symptoms. The environmental factors will probably be less dangerous once the eating disorder itself is properly addressed. This was a very thought-provoking post. Thanks.

Cathy (UK) said...

I very much agree that the first line of treatment for an ED is attaining a healthy weight and developing eating behaviours that enable the body to be properly nourished and function optimally.

Nevertheless, I disagree with the notion that there are never 'underlying issues' - (which provoke anxiety and depression) because in some cases there ARE. The ED behaviours themselves are very much self-perpetuating and their physiological/metabolic effects drive the illness; however, sometimes these behaviours start because the individual is traumatised (by bullying, rape etc.) and unable to deal with their emotions. Starvation, over-exercise, bingeing, purging (and self-harming) can all calm anxiety and help to regulate emotions - albeit destructively.

Too much emphasis is placed upon Key's (Minnesota) Starvation Experiment in explaining the aetiology of AN. For a start off, none of the participants resisted re-feeding or weight gain at the end of the study - which contrasts completely with the situation in AN. Yes, the participants became obsessive, compulsive and self-destructive when starved, but these behaviours (symptoms) rectified within a year of weight gain. Moreover, ALL of the men were described as physically and psychologically healthy at the start of the study. They didn't, like many people who develop AN, have a history of OCD and/or social anxiety and/or depression. And, the purpose of Key's study was not to study EDs, but to study effective means of re-feeding prisoners of war.

It might make you and some other people twitchy to hear terms 'underlying issues' and 'root' of an ED if you have never experienced trauma or bullying, but imagine how you might feel if you had experienced trauma and had started to restrict food to cope with the overwhelming emotions and anxiety such trauma elicited within your mind - yet professionals pooh-poohed your experiences? I know many people whose ED started after trauma - and they were most helped in recovery by professionals (and others) who validated their experiences.

EDs are not homogeneous illnesses throughout the population. If you were to study a large group of people with (e.g.) AN you would find a number of different triggers to their dietary restriction. For some it may have simply been fat phobia or body dissatisfaction, but for others the triggers may have been very traumatic. Some individuals starve themselves because of self-hatred following (e.g.) rape. Trauma and bullying CAN be underlying causes, and most people, whether traumatised or not use ED behaviours to regulate emotions, irrespective of their degree of starvation.

It is hugely unhelpful that there are psychiatry 'bibles' like the DSM which have compartmentalised mental illness into discrete entities - i.e. specific illnesses supposedly caused by a specific dysfunction of brain activity with a specific treatment regime (and often underpinned by heavily by research funded by very rich pharmaceutical companies).

I love your blog and your brain Carrie, but I cannot wholly agree with you on this one.

Fellow OCD Sufferer said...

Well said! I think much of the same can be said for OCD, as well. Thanks for another insightful post!

Anonymous said...

Been reading your book, Next to Nothing. This post reflects what you said over and over in the book- step one is ALWAYS treat the ED. Regain the weight. "Act" as if "recovered" before trying to figure out how to BE and STAY recovered.

I think it pays to address some of those "roots"- as roots of anxiety, perhaps, that caused the ED to emerge- not so much as roots of the ED itself. The ED is a master at manipulating and shape-shifting- it becomes the sufferer's best friend. It tailors itself to the situation- if a person is raped, it will be about the rape. If a person is overwhelmed w/academic stress when leaving for college, it will be about the academic stress.

I believe more and more the idea that it is a pre-disposed genetic/chemical issue, just like bipolar, ADHD, anxiety, etc. as you have said. I used to think my ED was my own- an issue particular just to me- a result of my particular traumas- but the more I research about it, and look at my family history (mom has depression, dad has ADHD, sisters have depression, ADHD, anxiety), the more I am convinced that this ED is simply the way MY chemical issues have exhibited. My issues that are no different than my parents' or my sisters'.

Whether or not I experienced this or that trauma may not have had anything to do w/the fact that I have this blasted ED. I may have had it regardless. BUT the mental anguish and damage I have from repeated traumas DOES impact how tightly the ED has a hold on me.

OF COURSE those things need to be addressed if I am to find new ways to cope w/the residual stress and hurt from them. But calling them the cause of the ED takes away from the simple fact that: I need to act differently in order to recover from this. Regardless of how I was hurt. I will be hurt again in life, too. But I am in charge of finding new ways to deal w/the hurts and stresses, w/out the ED.

Your posts rock. Your book does too. One last thought- I told my husband in despair that there is no point in climbing up the mountain (of recovery) b/c I can't see the top. He said, "Maybe there is no top. Maybe you'll always be going uphill. But maybe, at some point, it starts to level off. Maybe someday it's not so hard." Wise, wise man. So keep climbing- maybe it's ok if you can't see the top. After all, life is a journey, right? We can't stop traveling.

Anonymous said...

My daughter is recovering from an eating disorder. It's not all about the eating but yet it is the eating that keeps her healthy-periods coming, bones healthy, brain fully nourished and strong. She eats if she is happy or sad or anxious or depressed or mad or whatever- And gosh does she have those feelings! In spades and to her discontent much of the time. BUT, she knows if she doesn't eat, her brain chemistry will go wacky and life will be out of control before she knows it and she will have to travel this awful path of refeeding and recovery once again. Food is life! It's just her brain chemistry. In a way, no different than diabetes or any other awful disease that goes on and on. It's not fair (to her or to anyone in our family with these awful genetic curses) but that's something that just has to be accepted to move on...

I hope you all can get control of your own brain chemistry and eat no matter what else is going on. YES you will have to deal with it! But YES you can do it! Kick ed's booty!!!

anorexiaoni said...

Just for the record, right on Carrie and nice way of describing ED's 'friends'. I can see rereading my comment that I am not making my point clearly or coherently which is what you get when you post when you are half-awake... :s

I think my - seemingly unusual - issue is that I'm confronted with a fair few people in real life who overlook the 'friends' and focus on just food. It is, though, essential to tackle that, as everyone here says.

Anonymous said...

I think you need to be careful about how you word things sometimes. I think I get what you're saying but posts like these can come across as hugely invalidating to those who have suffered horrible trauma and abuse that still haunts them decades later. I know people who for years and years were unable to recover, partly because they never addressed these issues in treatment. Once they were forced to faces them and worked through them they were able to start recovering from their eating disorder. But ignoring it and "just eating" is not at all helpful. Please, have some compassion. Just because you don't have these issues does not mean many others don't.

Katie said...

To the final anonymous - I don't think Carrie WAS saying "just eat", she said throughout the post that she believed that co-morbid conditions and/or trauma must be addressed for full recovery. But there is something about starvation, bingeing and purging which can be incredibly addictive, and this will outlast the trauma issues if not addressed. I have a long history of PTSD, and even after I had recovered from most of it my eating disorder remained, because it was a disorder in it's own right as well as being perpetuated by my anxiety and PTSD. I believe that a person's genetic make up determines which sort of mental health problem(s) they will develop under stress. Some people who have been abused may become addicted to alcohol, some may develop an eating disorder. But the same person may well develop an eating disorder without ever having been abused, because they have the biological predisposition anyway.

Carrie, if I'm interpreting your post correctly, I agree with you. I know I'm really late to the commenting party but I was away this weekend, and I couldn't let this post pass because funnily enough, I wrote a very similar one on Friday :) it's always nice to see people take the same line of argument completely independentally!

Anonymous said...

Is it a lack of compassion to clean and bandage a bleeding wound on a sobbing child before taking them into your arms to snuggle them close?

For AN, the cleaning and bandaging involve food, fluids, and a few pounds- it's not a lack of compassion to focus on that first. It's responsible to do things in order. You wouldn't snuggle a wounded child first while his wound continues to bleed.

notpollyanna said...

I did have "underlying causes," but they were not the ones the professionals kept digging after. I couldn't talk about my trauma with them because, although they obviously believed what I experienced was traumatic, they assumed that it went further and that I was raped. They were so focused on getting me to admit I had been raped (nope) that they wouldn't let me talk about what DID happen.

As I experienced it, I was depressed and used an ED to cope with that depression. Same as I used self-injury. But for some reason an ED is understood to be its own entity, a discrete illness, while self-injury is more understood to be a symptom. I chose an ED as a coping mechanism. Perhaps my genetics were such that starving alleviated some of my anxiety, whereas it wouldn't for most normal people. Perhaps my genetics have something to do with why I got so depressed in the first place. I probably would not have chosen an ED if I hadn't been so depressed. But that doesn't change the fact that starving was, for me, a sort of choice.

For me, the first stage of recovery is eating food, yes. Then we can sort out which symptoms are starvation-induced and I can think more clearly to do the therapy work. Until the depression goes away, by drugs or by therapy, I tend to stay in a low grade ED mentality, strongly ambivalent. For me, resolving the problem that led me to choose to starve, depression, is vital to recovery from the ED, otherwise I can only get halfway there.

Joanna Cake said...

Im not sure whether it's genetic, but there is something within us that makes us predisposed to starving ourselves to deal with whatever it is that has upset us. There may be no major trauma, it may just have been a tiny thing/action/comment that triggered something inside our brain. Something so small that we don't even remember it but our brain responds by making us feel safer/more comfortable/more in control by restricting our food intake and upping our exercise regime. It's a coping mechanism.

I do believe that it's linked to OCD and I think that, once you stop starving yourself, you have to be careful that it doesn't find some other way of expressing itself.

Great blog btw.

BritishArtist said...

This is a powerful topic that really resonates with many people. I was certainly touched. Thanks so much for posting. I look forward to learning more.

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nevada public schools said...

Thank you! At my treatment center, all of these girls had sexual trauma, violence, kidnapping, all kinds of dramatic episodes in their past ... and here I was, with mild clinical depression, an ED, and no explanation for either. I felt like a fraud, like I didn't "deserve" my ED, or I wasn't really sick enough. I had to stop going to group because I was so negatively affected by these emotions. Of course there are comorbid or interacting factors that contribute to the intensity or manifestation of an ED, but I can't point to a single thing that caused me to be bulimic ... it was just the best coping mechanism I could find at the time. End of story.It's nice to hear someone else with that same personal history.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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nour·ish: (v); to sustain with food or nutriment; supply with what is necessary for life, health, and growth; to cherish, foster, keep alive; to strengthen, build up, or promote



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