Santa Barbara: one of the most breathtaking cities in the world. Deemed one of the most picturesque places to live, Santa Barbara emanates beauty from every vantage.  When I take a walk down State Street, visit the shops of Montecito, or spend an afternoon at the beach, I feel lucky to live in such a lovely place. And I can’t help but notice that the people appear just as lovely. Sometimes I wonder if behind the perfectly manicured appearance is an unfit pressure for a perfectly manicured life.

As a therapist who specializes in the treatment of eating disorders at Recovery Road Eating Disorder Programs, I see clients every day who’s struggle is far more than skin deep. Most lament a pressure to match their own physical allure with the appeal of this city.  However, for those who suffer with eating disorders, I know that it is about far more than vanity.

It is a common misconception that eating disorders are merely about being thin and looking good. While that might be what first meets the eye, beneath the pursuit of outward beauty are broken lives and hurting people. Eating disorders are very serious psychological disorders that require professional help. While much of our community values healthy eating and fitness, for those who suffer from eating disorders, these tenets are taken to the extreme and likely guise a very serious illness.

Typically, people with eating disorders are very good at portraying a picture-perfect image. They may appear happy, confident, successful, and popular. Oftentimes, they are the ones who seem to have it all together. However, I have worked in this field long enough to know that just beneath that façade is a lot of pain and brokenness. Controlling one’s food and body is a way to cope with overwhelming feelings or life circumstances. A person with an eating disorder turns to diet and exercise in much the same way that an addict turns to drugs or an alcoholic turns to alcohol. Paradoxically, obsessions with food and weight anesthetize unbearable emotional pain.

An eating disorder may start with an innocent diet or desire to lose ten pounds before summer. But for some, this diet spins out of control until it usurps one’s entire life. It becomes no longer about vanity, but about emotional survival. Of course, not everyone who wants to lose ten pounds develops an eating disorder. There are many genetic, cultural, and sociological factors that contribute to the development of this illness.

Those who develop eating disorders tend to be temperamentally people-pleasing, sensitive, perfectionistic, high-achievers, and have low self-esteem. While eating disorders are not limited to any one racial or economic group, they tend to manifest widely in upper socio-economic sets. And if you haven’t noticed, we live in one of the most expensive communities in the world!

Eating Disorders are tragically common in our beloved city. Santa Barbara exudes opulence, a thin and beauty ideal, and is home to many college campuses, which are known to be fertile grounds for eating disorders. In 2008, it was estimated that about 25% of students at UCSB struggled with an eating disorder.   Santa Barbara is also home to people with wrecked lives, broken families, financial and personal crisis. Situate these human conditions within a picture-perfect culture and we’ve got a perfect storm for eating disorders. Beneath the appearance of a manicured life is a messy reality.

At Recovery Road, I work with an incredible team of experts to help those with eating disorders to overcome their illnesses. We help people develop skills to cope with overwhelming emotions and to use tools other than their eating disorder behaviors to manage life. At Recovery Road, we understand that eating disorders are more than skin deep.

http://www.noozhawk.com/article/rachel_cantrell_eating_disorders_vanity_or_something_deeper/

Another signal went off inside my brain when a young man suffering from severe anorexia, attached to an IV pole receiving nourishment from TPN, referred off-handedly to the milky white substance being introduced into his body as “breast milk.” Recently, a colleague of mine mentioned that she has worked with clients who eat only pureed baby food.

Given these kinds of encounters, my wheels have begun to turn and I have started to explore more intentionally how eating disorders are like a substitute mother. Again and again, I see clients mimic their relationships with their mothers through their relationships with food or seek out some unmet emotional need through food. Let me explain what I mean.

Someone who consumes only baby foods may be expressing a deep need for mothering and caretaking. In a way, they may be saying, “I’m not ready to chew on solid foods and to digest more difficult sustenance  I am not ready to perform as a mature adult in the world. I need somebody else to do that work for me and to take care of me. I don’t have the necessary skills to take on more complicated tasks in the world.” In this way, the baby food acts as a symbol of profound developmental stunting and a a need for further skill development.

Furthermore, most people with an eating disorder would describe their addiction as both necessary to survival and extremely painful and destructive. For many, this reenacts the double-bind they have experienced with their mothers. They needed their mothers for survival, but there was some aspect of the relationship that felt damaging to their development of self. Each eating disorder generally takes on the unique “flavor” or quality of what the child experienced within their relationship with mom.

For others, their eating disorder provides a form of discipline, structure, and order. It provides rules and boundaries; order in a life of chaos. Perhaps they felt a lack of structure and discipline from the parenting they received, contributing to their perceived need to find it through control of food. Or perhaps they experienced parenting as excessively rigid and authoritarian, leaving little room for flexibility, grace, and freedom. One may then extend this dynamic to their relationship with food.

I have learned to look closely at the unique behaviors with food along with the associated feelings to find clues  into what necessary developmental tasks need to be completed. This helps me to then understand what the unmet emotional needs are so that my client and I can work together on ways to fulfill those in a healthy way and through genuine relationship with others.

Well, I actually  do not believe that the eating disorder is the problem. It merely masquerades as the problem. If we were to simply stop the behaviors without addressing underlying roots from which them stem, the behaviors would surely resurface. It’s like a pesty weed in your garden; if you merely prune the parts you see without digging out the roots, you’ll be coming back with your clippers next week and the next and the next.

I see an eating disorder as a solution to another problem. In fact, most of the time, I see that my clients’ eating disorders are pretty darn useful. Paradoxically, at times, I have even questioned my clients as to why on earth they would give it up. It has been working so well! (Facetiously of course. I would never actually advise someone to persist in harmful behaviors.)

I have watched eating disorders bring families together, foster cohesiveness between couples, and unite family members. I have witnessed eating disorders provide shelter and safety during life seasons of overwhelming distress. They have provided purpose for those without a sense of life meaning and whom might otherwise perform suicide. They have offered order and structure during times of chaos. They have provided discipline where parental exertion of limits in absent. They have created nurturance where parental love and attention is missing, friendship and companionship in places of deep isolation and loneliness, a sense of self where one is lacking. Without the eating disorder, many would be plunged into a dangerous pit of despair and possible death.

In no way am I suggesting that an eating disorder is a good idea or a permanent solution. However, it serves as a placeholder for a time while other structures can be put in place and other changes made to allow for long-term health. It’s a splint, if you will. Remove it prematurely without necessary development within self and family and collapse is inevitable. This is why the recovery process takes so much time! Recovery is not merely a removal of symptoms; it is a complete restructuring and rebuilding of self, family, and community. Eventually, my clients come to a place in their lives in which the eating disorder is no longer needed. The placeholder becomes obsolete. It is not uncommon for my clients to exclaim at the end of their grueling recovery process, “Thank God for my eating disorder!”

For those who struggle or have struggled with an eating disorder, this issue can become very tricky and confusing. While in the midst of a restrictive pattern, some may use fasting for religious purposes as a guise for their eating disorder behavior, whether consciously or unconsciously. It can be used as a good excuse to lose a few more pounds or to ward off uncomfortable questions from others about unusual food restriction. For those who are somewhere along the journey of recovery, this can be a tempting lure to the past “glory” days in which one experienced the high of restriction and that aloof feeling of power and control. It is far too easy to slip back into unhealthy patterns and a destructive mindset.

Regardless of one’s reasons for fasting or of one’s relationship with food, fasting, when unsubmitted and unchecked, can become  fertile ground for self-righteousness. It can become a private or public exhibition of false holiness. Rather than being a demonstration of submittance and reverence to God, it can become an inverted worship of self. One’s own self-control, self-discipline, and self-denial is on display. Soon, one’s goodness is equated with self-denial. Purity and holiness is measured by restraint and neglect. Badness and sinfulness is now equated with consumption. To become pure and good, one denies self. When ingesting sustenance, one is bad, a failure, unclean, sinful. Essentially, we are are now in the throws of eating disorder behavior and mentality.

This is not unlike the behavior of Saint Catherine of Sienna and many other catholic nuns who would engage in “anorexia mirabilis”, known as “miraculous lack of appetite”. This refers to women and girls of the Middle Ages who would starve themselves, sometimes to the point of death, in the name of God. The phenomenon is also known by the name “inedia prodigiosa”, or “prodigious fasting”. Women would attest to a sense of piety and enlightenment through severe starvation and self-flagellation.

Beneath the manifestation of Anorexia Nervosa is a desperate pursuit for goodness and holiness. The flip side is shame and guilt. Whenever food gets intermingled with morality and/or spirituality, I greatly caution my clients. For so many of my clients, especially those with Anorexia Nervosa, they need to know that they are worthy and deserving; that it is ok for them to receive pleasure. On a practical level, Anorexia Nervosa is a rejection of life-giving sustenance. On a deeper level, Anorexia Nervosa is a passive putting to death of self. Thus, it is necessary that one come to believe that she is worthy of life. That she can be worthy of life and be good at the same time.

I have found that for those with eating disorders, it is helpful to keep food as food and not as a tool for spiritual expression. The possibility for relapse is just too great. I recommend substituting something else (T.V., Facebook, gym). However, I even caution against fasting other items or activities until one is very solid in recovery. Because Anorexia Nervosa is not merely a rejection of food but an all-encompassing restrictive nature to life, restriction of any sort can trigger the anorectic process.  Finding counsel from friends, trusted spiritual leaders, or a therapist can help bring discernment in this difficulty area.

Over time in my work with my clients, I have begun to see a certain trend of identity theft.  What I mean is that my clients have had their identity stolen from them and replaced by that of another. (In fact, later in life, if they have not done the work of getting to know and embody who they truly are, they turn around and steal the identity of others.) In this way, they have come to live, think, and operate as that of another. Not that this happens in some dramatic one-time event. Quite the contrary. It happen slowly and insidiously over time. It can happen in any miriad of ways. Take for example some of the following interchanges between hypothetical parent and child:

“Ow! I hurt my knee!”

“Oh, you’re not hurt. You’re fine. Stop crying.

“I don’t now what to do this year. I might want to try our for dance.”

“No you don’t. Dance is for wimps. You want to play soccer. That’s what I played when I was your age.”

“I hate school. I don’t want to go.”

” Everybody hates school. When I was young, I made friend really easily. You should do what I did.”

In each of these cases, the child’s  thoughts and feelings are negated or superimposed by those of the parent’s. It can even be as subtle as a parent suggesting to wear your hair a certain way or to change your outfit to look a little better. Usually, this dynamic meshes with a people-pleasing personality to create fertile ground for an eating disorder. Just to make it through life without conflict, one learns to suppress one’s own thoughts, feelings, and opinions and acquiesce to those of others. But pretty soon, you’re living a false life with a full-blown eating disorder to testify that you’re living inauthentically. Ironically. this is your gift!  This is your signal that something is out of alignment.

The joy of recovery is that you get to come back into alignment with who you are made to be and how you are designed to live.

Crucial to this process is the mother’s own developed secure self. She uses her own secure self to foster the infant’s development of self. Holding onto her own feelings, needs, thoughts, etc., she reflects back to her child its feelings, needs, thoughts, etc. The mother extends herself to care for her baby, neither abandoning her own self nor engulfing her baby’s self into her own. The mother, having accomplished her own secure attachment to self, is unthreatened by the little life developing in front of her.

As mom responds to the infant’s cries for love, touch, food, sleep, etc., the infant learns that it’s needs are important and she feels a sense of trust that her needs will be cared for. When mom responds to the child’s emotions, even giving language to the feelings expressed, the child identifies with these emotions and incorporates them into her schema. The child learns that her emotions are good, right, and safe. She learns that her emotions serve a purpose to fill a certain need for love, touch, food, sleep, safety, etc. Over time, ideally the child learns to self-sooth, fostered by an overall secure attachment with the primary caregiver. Throughout this process, the child develops a sense of self as separate from other. She learns that she is separate from mom while simultaneously being held in a  safe, nurturing bond. She is free to venture out and become an individual, separate from and different than mom.

Of course, this ideal process of individuation doesn’t always happen as intended. Research is showing that many with eating disorders experienced disorganized attachment in the early years of life. (Mark Schwarts, IAEDP Conference, 2006)  Practically speaking, all looks “normal” from the outside. Mom picks up and holds the baby. She feeds, rocks, and attends to the baby. Later in life, she pays for summer camp and attends three soccer games a week. But overall, there is a narcissistic quality to the mother’s love. The relationship seems to serve the mother’s own needs more than it does the child’s. There is the appearance and form of connection with the absence of a true emotional bond. Later in life, the child may wonder why she feels so empty or disconnected because everything looks so perfect on the outside.

This type of disorganized attachment in which the relationship serves, in some way, to feed the mother’s own undeveloped self, leaves the child emotionally undernourished and void of self. Rather than developing an internal reference point, she has developed an external reference point. She has been taught that her identity, purpose, and feelings are contingent upon those of another. Therefore, she filters everything through an external lens. She questions, “what does mom want?” rather than “what do I want?” This general mode of operation later extends to others and in all sorts of situations. She is so busy living from the outside that she doesn’t know how she feels, what she wants, or if she’s hungry. Recovery entails the long process of discovering how to live from the inside out and how to develop a strong internal attachment to one’s own self.

Most of us have some idea of how we feel, think, believe, perceive. We have an internal reference point from which we approach life and interact with the world. Someone with an eating disorder, however, lacks that home base, so to speak. Instead, they have been operating from external reference points. They have used external markers, such as body image, expectations, achievements, other’s opinions of them, etc., to formulate a sense of identity. This mode of operating from the outside in is what formulates the eating disorder.

The eating disorder serves a very important purpose of formulating a pseudo-self. Imagine how scary it would be for someone to just give that up! There’s nothing but blankness or emptiness left. That’s why simply removing the symptoms without doing the internal work of recovery doesn’t last. Relapse is inevitable. Sometimes I think of the eating disorder as a place holder that helps my clients get through life while they take time to develop their true selves. Once someone discovers who they truly are, which is a  long, arduous, and exciting process, the eating disorder is out of a job. For me, working with those with eating disorders is a great honor because I get to witness before my very eyes people come into who they were truly made to me.

Most abide by the belief that some combination of genetics, culture, and family dynamics contributes to the development of eating disorders: society is the gun, genetics loads the gun, and the family pulls the trigger. Unfortunately, many afflicted individuals and their families have lived with a negative stigma associated with this disorder. Until recently, most research had been devoted to the sociological contributing factors to the disorder, highlighting the role that family can play in the development of eating disorders. Consequently, too much blame has been unduly placed on families. Leading research in the field is now turning towards genetic and neurobiological contributing factors.

Researchers at the University of California, San Diego Medical Center are looking at how the brain may contribute to the development of the disease Anorexia Nervosa (AN). Walter Kaye, Director of the Eating Disorders Program at UCSD, and his colleagues found that behavioral commonalities amongst those affected point to the possibility of underlying neurobiological factors: “They often become sick around the same time (early adolescence), show similar symptoms and behaviors, and are mostly females. They typically resist eating and engage in a powerful pursuit of weight loss, yet paradoxically are obsessed with food and eating rituals. Even when underweight, they tend to see themselves as fat and deny being underweight. They tend to resist treatment and lack insight about the seriousness of the medical consequences of AN.”

So is this eating disorder really a brain disorder? Anorexia patients exhibit reduced brain volume, altered metabolism of brain regions known to modulate thought and emotion, and a return to childhood levels of female hormones. These disruptions tend to normalize with weight restoration, suggesting that they are consequences of AN rather than causes.  Furthermore, AN patients demonstrate that their higher brain regions, such as the frontal cortex, are able to override or ignore signals sent from the lower brain regions such as the hypothalamus which signal starvation and the need for food intake. These higher brain regions play a critical role in emotions, personality, and rewards, all important components in AN.

Genes play a huge role in causing eating disorders, contributing to certain personality traits that increase the risk of developing AN. People who develop AN tend to possess similar characteristics even in childhood, including anxiety, depression, perfectionism, people-pleasing behaviors, obsessiveness, and a drive for thinness.  These traits also tend to persist after recovery. Kaye et. al. point out “they tend to be rule abiding, rigid, and anxious children who are high in harm avoidance, a personality trait characterized by a tendency to criticize and doubt past thoughts and behaviors, worry about the future, and struggle with uncertainty.” Studies have shown that these traits are heritable and found in family members of AN patients irregardless of weight. Because these personality traits persist into recovery, it is suspected that they reflect underlying traits rather than consequences of anorexia.

Appetite is regulated by a complex system of nerve signals and hormones in the brain, gut, and fat and sugar stores throughout the body. Imaging studies show that higher brain structures in those with AN are used to override signals and to cognitively control and restrict eating. Brain scans show distinct differences between the brains of those with AN and the brains of those without it. Many of these differences are found in the insula. During a sweet-perception task, people without AN are given sugar and the more they report that they enjoy the sugar, the more activity shows up in their insula, striatum, and ACC.  Thus, these regions of the brain are important for sensing reward.  When given the same test, people recovered from AN show less activity in these areas when given sugar.

Similarly, when looking at pictures of food, both ill and recovered anorexics show altered activity in the insula, OFC (orbitofrontal cortex), mesial temporal and parietal cortex, and the ACC (anterior cingulate cortex). Furthermore, people recovered from AN show less activity in the insula and other parts of the neural network.  This suggests that the “ability to perceive palatable taste is fundamentally altered in AN, even after recovery, and that people with AN have a reduced incentive and/or motivation to approach food.” Overall, these imaging studies suggest that people with AN have a reduced drive in several systems associated with hunger and appetite, which explains how it’s possible for many to pursue emaciation even to the point of death. Unlike those without the disease who experience food as more rewarding when hungry because of neural pathways in the brain becoming more active, driving the motivation to eat, those with AN seem to received mixed messages from various parts of the brain. This may explain why food and cooking obsessions are paired with lack of motivation to eat.

Lastly, recent studies have assessed reward processing in AN. The neurotransmitter dopamine is involved in reward and affect, decision-making, and executive control. There is much evidence that alterned function of dopamine occurs in AN. Kaye and his associates conducted a study in which healthy controls and those with AN were assessed for brain activity response to winning or losing money. In controls, the neural activity for winning was very different from that of losing. But in people recovered from AN, the brain activity in the ACC and its ventral striatal target was similar whether they won or lost. “This suggests that people with AN might have trouble discriminating between positive and negative feedback and identifying the emotional significance of stimuli, which in turn could help explain why it is so tough to motivate them to go into treatment or to appreciate the consequences of their behaviors.”

Kaye et. al. also found that women who were recovered from AN showed increased activity in certain areas of the brain (DLPFC and the parietal cortex). These regions are activated when there is a perceived connection between action and outcome and when there is some uncertainty about whether the action will lead to a desired outcome. Healthy controls were able to live in the moment, make a guess, and then move on. However, those recovered from AN “tended to worry about the consequences of their behaviors, looking for “rules” when there were none, and feeling overly concerned about making mistakes.”

In conclusion, AN is a very complex disorder with etiology stemming from the interaction of genetic, biological, psychological, and sociological factors. More and more research is finding that there are actual brain and neurological changes that occur in those with AN. It is not in their head! (Well, actually it is…literally… in their brain chemistry and anatomy) It’s an actual, real life disease, and it’s my hope that those who suffer from the disorder can find some solice in knowing that they are not somehow defective and that it’s very difficult to “just get over it.” When they are feeling disconnected from their feelings, for example, there are actual neurobiological reasons for this in their brains. My hope is that as new information continues to surface, the shame and guilt can be removed from the disorder and we can respect it like we do any other disease.

Source:

Kaye, Walter H, et. al. Is Anorexia Nervosa An Eating Disorder? How neurobiology can help us understand the puzzling eating symptoms of anorexia nervosa.
http://eatingdisorders.ucsd.edu/research/biocorrelates/PDFs/Kaye2010NeurobiologyofAN.pdf

Glamour conducted a survey of more than 300 women of all sizes. They found that, on average, women have 13 negative body thoughts daily. Some women even attest to having 50 or 100 hateful thoughts about their bodies each day. Cultural ideals about weight and beauty certainly play a part. But we’ve also trained ourselves to think this way. Neuroscience has actually shown that whatever we focus on shapes our brain. Neural pathways form according to what we habitually think about. Unfortunately, this training begins very early. A study conducted at the University of Central Florida shows that, of three to six year old girls, nearly half were already worried about being fat and about a third stated that they wanted to change something about their body.

When Glamour went to analyze their data in efforts to find a cause for these negative thoughts, an interesting trend emerged: They found that participants who were unsatisfied with their career or relationship tended to report more negative body thoughts than women who were content in those areas. In fact, uncomfortable emotions of any kind, such as stress, l0neliness, or even boredom, influenced women to start berating their bodies.

I often talk with my patients about “fat attacks”. This is what I call that sudden, out of the blue fear and panic associated with feeling incredibly huge. It can seem to come out of nowhere. One minute, you’re feeling fine, and the next, you can feel as big as a blimp.  Nothing changed in the last few moments about your body. It’s the same one you had when you feeling fine about it. The only thing that changed was an emotional state. Perhaps you’re feeling overwhelmed about all of the things you have to do that day. Or perhaps you’re angry with your boss, or frustrated with the mess the dog has made in the living room. These emotions can come so quickly, and people with eating disorders are so disconnected from their emotions, that all of this gets channeled into body image. However, all the dieting in the world won’t make you feel better, because the issue was never about that in the first place.

In her article “Body Talk: The Use of Metaphor and Storytelling in Body Image Treatment”, Anita Johnston writes, ” A woman who struggles with body image issues tells herself a story (“I’m too fat” or “I am ugly”) but fails to question what is real and true. She is not conscious of the inner stories that are causing her great suffering… Because her physical appearance is the first thing that appears to her when she looks at herself, the first thing she sees when she senses something is wrong, she turns the full force of her fear, disgust, and rage against it.” As Anita so powerfully articulates, a woman who does not pause to examine the full picture of her life responds instead to the initial thought that comes into her mind. For example, “He doesn’t like me because I’m too fat.” She immediately assumes that the culprit is her body, which houses her appetites and desires, which has now become the enemy that has caused her all of her pain and anguish.

If we would pause long enough to assess the real issues and concerns in our lives, we would realize that the problem is not our bodies. It’s our inner critic. Our bodies are nearly messengers alerting us to the real issues: pain of divorce, loneliness of being rejected, worry about being our of a job etc. Negative body image is merely a red herring, convincing us that the problem is that we’re too fat, and deterring us from the real issues causing the pain. As long as we persistently focus on changing our bodies, the real underlying issues never get addressed and resolved. I ran across a quote somewhere that has stuck with me: “In order to see the moon, you must allow your gaze to go beyond the finger pointing to it.”

In the same way, therapists know that  food is an integral part of the recovery process for an anorexic. But their anorexic patients don’t want to get better. They won’t take the “pill”. This disease is particularly difficult to treat because, while the patients are dying before their very eyes, they want to keep their disease. It works for them. The psychological term for this is “ego-syntonic”. It means that the behaviors and effects of their anorexia make them feel good. While the feeling of hunger for a “normal” person is unpleasant, it feels good, even euphoric, for an anorexic. While lethargy and sluggishness is a drag for most people, these feelings are reward and reassurance for someone with anorexia. Most females are concerned when they are a-menstrual for several months.  An anorexic likes this because it tells her that her starvation is working and she is still underweight.

Rather than feel calm and safe when satiated, anorexics feel extremely anxious and fearful; like crawling out of their skin. Hunger does not create a feeling of anxiety like it does for those who respond to our instinctual need to find food when hungry. Instead, it actually creates a feeling of calm and numbness. Not eating for an anorexic makes them feel victorious. The behaviors of this disease cause someone to feel competent, in control, even invincible. Who would want to give that up!?

This is why suggestions such as “just eat” or “why don’t you have a sandwich” don’t work for someone suffering from this disease. Recovery is not as quick as just popping a pill. It requires long and tedious work of meeting the underlying emotional needs until the behaviors are no longer needed. It also requires working with the afflicted to help them also see how their disease is not working for them. Until this realization breaks through the heavy denial, treatment will most probably be unsuccessful. Once someone realizes, at least on some level, that their disease is no longer accomplishing for them all that it originally did, change and recovery is much more possible.