There are many types of eating disorders but the most prevalent ones are know to be anorexia nervosa, bulimia and binge eating disorder (BED). Nutritional nervosa, which is characterised by obsessing over nutrition also seems to be gaining importance with the rise of clean eating. As with any other disorder, a person does not need to be officially diagnosed with an eating disorder for them to be suffering from it’s symptoms. One may present with traits of an eating disorder but not meet official diagnostic criteria of one. Apart from the behaviour related directly to the condition itself, eating disorders are often accompanied by anxiety, depression and obsessive compulsive traits.
Eating disorders are not the core problem—they are the symptom of the core problem. They are there because of disruption of relational contact in individual’s developmental history.
Sense of self and identity
One of indicative characteristics of eating disorders is the sense of self and the sense of identity. People with eating disorders tend to have poor sense of self—often deriving from their early developmental history. They grew up with an experience that they need to put the needs of others first—if not they feel as bad, worthless or guilty. Their sense of self is directly tied to how they make others feel and how they take care of others. They learned this with their parents and are now doing it with their current relationships.
Developmentally, their childhood eating patterns were sometimes a form of satisfying their parents and keeping them happy—e.g. not psychologically maturing sexually or even not growing up and psychologically separating from their parents. Sometimes an eating disorder is a way to avoid expression of sexuality or being perceived as sexually mature—this is especially the case with anorexia nervosa.
Eating disorders thrive on perfectionism
Eating disorders often accompany other disorders. When they are present only with traits and do not meet diagnostic criteria, we often see them with personality structures of people with extreme need for perfectionism—sometimes accompanying other forms of obsessive compulsive behaviour. They are in them selves a combination of obsessive compulsiveness—predominantly to avoid feeling feelings that they perceive as unacceptable or dangerous.
(Related reading: Obsessive-Compulsive Disorder—OCD)
(Related reading: Obsessive-Compulsive Personality Disorder—OCPD)
But the higher the level of perfectionism, the more room for errors and the more catastrophic the errors can be. More errors will inevitably mean more self-criticism, which will require more self-soothing. However, if the individual never learned to self-soothe, regulate their emotions, experience them authentically and in a healthy manner, this will get them into a vicious cycle of putting themselves down, binge eating, and then putting themselves down for that again.
Not feeling and fear of feeling are at the core of any eating disorder
Individuals that suffer from traits of eating disorders were often not allowed to feel certain feelings—e.g. fear, anger, sadness. Sometimes feeling or expressing them would be painful or even dangerous. So they learned to use food to distract them, sometimes dissociate and prevent them from feeling.
All this was a way of maintaining a psychological (symbiotic) tie with their parents and avoid perceived rejection or danger. It was a form of pleasing their parents, controlling them, adapting to how they wanted them to be as children. Because of the lack of emotional contact with their parents and because their feelings were not acknowledged, some individuals have as children learned to soothe their discomfort with food. They just did not know what to do with their unpleasant feelings (fear, anger, sadness), however, they knew that expressing them would not be safe for them.
They are now bringing the same sort of dynamics into their current relationships whereby they tend to please others and care for their wellbeing and feelings more than for their own. Pleasing others is their way of maintaining relationships. When conflicts arise, they will usually blame themselves and sooth their feelings by binge eating or obsessive weight control.
Treatment of eating disorders in psychotherapy
We can easily fall into trap and consider eating disorders as the main presenting problem and the object of addressing in therapy. We should, however, rather consider it as a symptom of intra-psychic and psychological processes that result in eating disorder behaviour. It is important to address the underlying issue in therapy, rather than confront binge eating or any other manifestation of the disorder.
To further emphasise the importance in treating the psychological causes that underpin eating disorder and not the eating disorder itself, it should be pointed out that for example in the treatment of bulimia focusing on the bulimic behaviour can actually be counterproductive.
An important focus also needs to be on emotional fluency; to bring the primary feelings out and help the client process and deal with them in an authentic manner. This will automatically reduce the need for repressing their feelings with binge eating or wight control obsession.
Finally, it is important to emphasise that eating disorders can have extremely complex intra-psychic foundations, which can differ considerably among different individuals. It is therefore important to fully understand the client well to help them tackle their problem.