Eating Disorder Referral and Information Center
International Eating Disorder Referral Organization
Why eating disorders aren’t entirely about food
by Carolyn Coker Ross, MD, MPH
“Illness of any kind is a ‘call to action.’ The action you choose will either lead you on your own journey to healing or the call will be repeated over and over again with higher intensity until it is answered. Carolyn Ross, MD (from Miracles in Healing).
This article provides a deeper understanding of the “building blocks” of eating disorders: the superficial diagnosis, the emotional soup, the sensate layer of expression, the core beliefs, and the deeper urges of the soul. These layers of personal expression contribute to and drive the engine of eating disorder and result in disordered eating.
Emma was like a deer caught in the headlights of a semi bearing down on a dark stretch of barren highway. Her hand movements when she talked were rapid and disordered, as was her speech. Her body had an athletic build and appeared tense, taut, as if she wanted to spring up from the chair in my office and run away from whatever demons haunted her. Her story was full of contradictions. She was a heavy drinker, drinking ten or more beers every night and more on the weekends. She used over a gram of cocaine daily and thrown into that mix was abuse of amphetamines several times a week. She described her bulimia as being out of control, with episodes of bingeing and self-induced vomiting up to five times per day. She was taking several prescription medications to control her anxiety and depression. She told me: “I can’t go on like this anymore.” Given all of this and what I was to learn later in my work with her, I couldn’t figure out how she’d held it together for as long as she had. She was a student in a high-powered graduate program on the East Coast. I wasn’t as surprised at her choice of profession as much as I was that she was able to maintain a 4.0 GPA given her drug use and bulimia.
Emma’s recent breakup with her boyfriend of two years triggered her admission to our inpatient eating disorder program. She cried as she told me how her drug addiction and eating disorder had caused the breakup. “I thought I had it under control. But Mark found out I was using again and he couldn’t take it anymore.”
Emma’s mother was an alcoholic who drank heavily throughout all of Emma’s childhood and was drinking still. Her parents had divorced when she was eight years old, and this was a pivotal time in her life. After the divorce, Emma was left to take care of herself and deal with her mother and a stepfather who sexually abused her between the ages of nine and thirteen. In high school, she was date raped. Unless Emma could heal the trauma and rape and neglect, it would be difficult if not impossible for her to stop pushing down her emotions with bingeing or purging when they overwhelmed her.
Emma had survived the neglect of an alcoholic mother, the abuse of her stepfather, and a date rape without telling anyone. Many people with eating disorders have hidden trauma or neglect somewhere in their past and are in need of healing for their body, mind, and spirit. Without dealing with deep wounds such as those that Emma suffered, without identifying the root cause of the behaviors that are so obviously self-destructive, true healing of body, mind, and spirit cannot occur. Emma’s depression and anxiety had been treated with medications. She had been in outpatient therapy for several years. Yet she continued to experience and to suffocate emotions of rage, shame, guilt, and fear associated with the trauma and neglect she suffered as a young child. What had changed in her? How had she coped? Why was she not able to “cope” any longer? The delicate balance in Emma’s life was upset by the breakup with her boyfriend, which then unleashed many of the emotions she had been numbing herself from with drugs and her eating disorder. This event led to her being admitted for treatment and began her personal journey toward healing body, mind and spirit.
Healing body, mind, and spirit in this integrative medicine approach to treating eating disorders requires not only the use of different therapies. A philosophical shift is the underpinning of this approach and starts with an understanding of how to help those with eating disorders get to the root causes and to heal at this level first.
Superficial Level of Behaviors:
What we see when patients present for treatment are the superficial behaviors that have become severe enough to catch their attention or the attention of their family and friends. They may be starving themselves and/or binge eating with or without compensatory self-induced vomiting. They leave the dinner table early or make excuses to take a separate car so they can purge whatever they have eaten. They run up credit cards with the exorbitant amount of binge foods they consume. Or they become rail thin, their faces the skeletal death mask of anorexia. They may use drugs or drink to excess. Sometimes the drugs are in the service of their drive to be thinner and thinner. Or, drinking and drugging serve to make them numb and keep the feelings at bay. They may exercise three hours a day, sometimes going to the gym or running at 3 am to avoid scrutiny. Often they are so weak that they may have to reduce their exercise because of shortness of breath and fatigue. Every day, their minds are preoccupied with thoughts of how they look, how much or how little they should eat, fear of getting fat, and thoughts of self-hatred and disgust about their appearance. Often these thoughts occupy 100 percent of their daily lives, crowding out all thoughts that are not in the service of the eating disorder. As these behaviors progress, they become more isolated, losing friends and relationships as these take a backseat to their preoccupation with the eating disorder. These behaviors are what bring someone suffering from an eating disorder to treatment, but they are only the beginning of understanding the deeper root causes.
Beneath the superficial layer of behaviors is a boiling cauldron of unexposed and suppressed emotions. It is important to focus on getting to the root causes of the “dis-ease” of which the eating disorder is a symptom. Underlying the behaviors of eating disorders and their associated diagnoses such as substance use disorder or depression or anxiety is the emotional landscape that people are trying so desperately to avoid, escape, or suppress. This emotional layer is often confusing for people to sort through as was the case with Bethany:
Bethany was admitted for treatment of bulimia nervosa that had come to light during a three-month hospitalization at a well-known medical hospital for treatment of severe recurrent depression with chronic suicidal thoughts. Despite numerous medications and long-term outpatient therapy, Bethany remained depressed. She had had a normal childhood until her parents divorced and her father moved to another city. After that, the family’s finances changed. Bethany was moved from a private school where she had done quite well to a public school where she felt bored and less “special.” Her mother was no longer able to afford the singing lessons that Bethany had loved so much.
Other than these events, there were no other significant traumas in her life. During one of our sessions, I asked Bethany to draw three pictures: one to depict her emotions at the time of her parent’s divorce, another when her eating disorder started at age fourteen, and the final one to demonstrate her current emotions. The first picture was a scrawl of bright red crayon covering the entire page that screamed “I am ANGRY!” The second picture showed the bright red scrawls being covered up with dark purple, which she interpreted as her attempt to cover up the anger that had never gone away or been acknowledged. The final picture showed the bright red scrawls again covered over with dark purple and on top of this, black was painted over the purple and the red, demonstrating the dark oblivion of her depression and the final attempt to suppress her anger. Bethany was surprised that she felt anger at all, so complete was the cover-up. By unveiling her anger, she opened the door to a deeper possibility of healing.
Bethany demonstrates the primeval emotional soup that many suffering with eating disorders swim in when feelings suppressed in childhood get obscured over many years into adulthood so that they become very difficult to recognize.
Beneath this emotional soup is the sensate level of emotions that are felt and sometimes trapped in our bodies. This concept is central to effectiveness of many of the CAM body therapies that we will discuss and can often be understood in terms of metaphors: shoulder spasm from the stress of working too much can be described as “carrying the weight of the world on your shoulders.” Uncovering the many layers of the emotional soup and their attendant physical manifestations allows one to uncover deeply held beliefs that are blocks to the self-healing process.
Because persons with eating disorders are disconnected from their physical bodies, they do not receive any of the cues that would force them to eat or stop eating in response to hunger and satiety or to stop exercising before they injure their bodies. Their complete attention is focused on their eating disorder thoughts, those negative, self-defeating thoughts that bombard their waking minutes, seeking always to destroy the individual.
Therefore, one key to healing body, mind, and spirit is to reconnect with the body and to remember how to experience emotions in the body. What does anger feel like? Is anger signaled by a flush of heat and reddening of the face? Does anger feel like tightness in the shoulders or chest? How does fear feel? Or anxiety? Or shame? Little by little, it is important to be able to recognize the sensations from the body and to understand that they are cues to our innermost feelings, feelings that have been submerged through the use of food, drugs, drinking, or compulsive sex. The sensations in the body are the key to unlocking the emotions and removing oneself from the primeval emotional soup.
Core beliefs lie beneath the emotional soup and sensate level and are the pivotal points on which the eating disorder and addictions have been honed. Getting at these core beliefs can be difficult, although once recognized, they form a “light bulb” moment that can transform one’s attachment to and understanding of the origins of an eating disorder.
George presented for treatment at the age of forty-three. He was married with two young sons and worked in his own business in Detroit, Michigan. George was a compulsive overeater who at six-foot-three weighed close to four hundred pounds. He had struggled with his weight since childhood. In treatment, he was able to get in touch with a great deal of anger toward his mother. As a young child, he had been sickly and his mother was overprotective. When he and his brother got into trouble, they got punished and he did not. Over time, this led to his being teased by his older brother. At about the age of fourteen, he was taller and was heavier than his brother John. During one of their many fights, George became so enraged that he literally broke down John’s bedroom door. In an instant, he realized that John was actually afraid of him and his rage for the first time ever. George remembers having the thought in that instant: “big is good.”
This became his long-forgotten core belief that would sabotage future efforts to lose weight. Being big was his protection and his power. Being big was the equalizer between his tormentor and himself. The need to “be big” to have power also became generalized to other stressful situations. For example, in his marriage, where his wife’s financial prowess gave her an advantage in the power differential of their marriage, being big helped to ease some of the loss of self-esteem he felt not being the primary breadwinner.
Core beliefs represent essential human needs: the need for love, nurturing or acceptance. Core beliefs are the result of chronic stressors that remain unresolved or of extreme emotions. As such, they remain very deeply in memory. These beliefs then shape future behaviors but surreptitiously are unremembered. Therefore, the behaviors would appear to contradict one’s stated goals. For example, George wanted to lose weight and he was often successful in doing so, but inevitably the weight would return and very quickly. Armed with an understanding of at least one of the core beliefs that would sabotage his weight loss, he was more aware and more able to intervene and change this belief. For his child-self, big was good. As an adult, being big or obese was killing him. He had developed high cholesterol and insulin resistance as well as high blood pressure. He was often easily fatigued and unable to play with his children in the way he would have liked. “Big” had helped him deal with a childhood in which he was teased and felt afraid of his older brother, but it was no longer an asset; instead, it was a liability.
Deeper Urges of the Soul:
One does not have to believe in religion or even have a belief in a “higher power” to understand and acknowledge the deeper urges of the soul or spirit. These urges are sometimes called our “bliss” or passion in life. Most importantly, the deeper urges are our own unique, individual method of self-expression. Self-expression is hampered when our focus, thoughts, and energy are 100 percent occupied with eating disorder thinking. While one may continue attempting to go to school or maintain a successful career or be an ideal mother, the deck will be stacked against being successful or experiencing happiness while doing these things he or she may treasure because of the elaborate structure required for emotion control. Often, when restored to a more complete way of functioning, it’s possible to realize that what was considered one’s best performance at work, for example, didn’t come close to what one is able to do when well. There is no way for persons under the influence of an eating disorder to get in touch with these spiritual longings until they move through and clear out the layers of their elaborate structure—the superficial behaviors and emotional soup—then get back in touch with their bodies through the sensations and core beliefs layers. Once this is accomplished, the stirrings of their spirit/soul begin to percolate to the surface, bringing along a renewed vigor for and purpose in life.
Note about the author: Carolyn Coker Ross, MD, MPH is the Head of the Eating Disorders Program and the Integrative Therapies Department at Sierra Tucson. She is a nationally known speaker on women’s health, eating disorders and integrative medicine. She has a small private practice in Tucson doing consulting and treating clients with eating disorders and obesity. She can be reached through her website: www.carolynrossmd.com or by email: email@example.com.
Name and identifying details changed to protect patient privacy. All cases are composites of various cases of patients the author has treated in her 25 years of medicine.
The views and opinions expressed in this article are strictly those of the author and are presented without editing. The opinions expressed herein do not necessarily reflect the position or the policy of EDReferral.com, and no official endorsement by EDReferral.com of the opinions expressed herein should be inferred.
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