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Identifying the Disorder
The desire for weight loss is the most common starting point for an eating disorder. It can begin innocently enough, with the desire to lose weight and look better. But for some people the physical changes that weight loss brings about are so seductive, the praise they receive from others is so gratifying, that they feel compelled to further diet. Changes in brain chemistry brought about by weight loss can also reinforce these limits, and, as if something is set in motion, an eating disorder is soon in place. Other factors may also come into play. Having an illness that leads to appetite loss and weight loss may start an eating disorder. A significant change in circumstances, such as a divorce, a death in the family, or a move, can make an individual vulnerable. Positive events such as a wedding or a new job may also be responsible. Sometimes, people will restrict (or, in the opposite direction, binge) in an attempt to combat anxiety, and possibly depression. And sometimes, even an offhand remark like 'You've put on a few pounds' can be enough to get someone started down the road to an eating disorder. Whatever the trigger, it's important to know that eating disorders do not come about by choice.
How Does It Start?
Ironically, the eating disorder, which can represent a profound threat to a person's health, can often be traced back to a desire at first to become healthier, a desire that finds expression in a weight-loss diet and sometimes exercise. Most people who decide to go on a diet end up following a script that has a predictable ending. The dieter will adhere to the advice given in just about every diet book—restrict food intake and exercise more—and that generally works for about the first month or so. The first couple of weeks are very gratifying because most people will lose several pounds quickly. The next couple of weeks are harder—the weight comes off more slowly, and the hunger pains and sense of deprivation grow. By the end of the month, the dieter has lost perhaps ten pounds, but weight loss has stalled. At that point the denials and rationalizations begin: 'One cookie won't make a difference.' 'I've been so good I deserve this treat.' 'I'll take a break today and be good tomorrow.' The diet and exercise stop. The lost weight gradually returns.
For some people, going on a weight-loss diet seems to
trigger something in them. They find a deep satisfaction
in restriction and a deep gratification in weight loss. For these people, the sense of accomplishment that comes
with weight loss, along with the praise and admiration
they receive as a result, gives them a new identity, the identity of someone who's really good at being disciplined and losing weight.
A Spectrum Disorder
Eating disorders range across a spectrum. At one end are people with extreme anorexia who severely restrict their food intake; at the other are binge eaters and compulsive overeaters who can't control their desire to eat large quantities of food. Also included in that spectrum are people with bulimia, who may binge on food and then purge by vomiting, overexercising, or using laxatives or diuretics. The intensity of a disorder can change over time for each individual, and often the distinctions between one category and another are blurred. Eating disorders are generally associated with extreme weight loss and emaciation from anorexia, but in reality anorexia is just one aspect of the broader eating disorder spectrum. In fact, someone who's overweight could become anorexic or might turn to bulimic behavior and still appear overweight.
What all patients with eating disorders have in common is an inability to see themselves as they are. While these people can generally look at others and see that they're a normal weight, or too thin or too heavy, when they look at themselves they see only a distorted image. One end of the spectrum is significantly underweight, while the other end of the spectrum is significantly overweight. Throughout the entire spectrum the mirror consistently gives a distorted reflection to someone with any eating disorder.
For others, however, the physical changes in the body offer concrete evidence that efforts are paying off. This is motivating, as is the realization that the cause and effect of diet and weight loss are straightforward in a way that little else is. But as she restricts her diet more and more, as she loses more and more weight, any tendencies the person might have toward obsessive-compulsive disorder and perfectionism, two common characteristics of individuals with eating disorders, have an opportunity to really blossom. And as she loses more and more weight, she discovers something else. Weight loss feels good because it helps to calm the high level of anxiety that is another common characteristic of individuals with eating disorders. Being in a state of semistarvation causes changes in the metabolism and brain chemistry that reinforce the restricting behavior by creating a natural high. Further reinforcement comes from family and friends, especially peers. They're all saying, 'Wow, you look great' and 'I really admire all your hard work.' Now the person is not only feeling the high but also getting all this reinforcement. It appears to be a win-win situation, but the end result is a serious eating disorder.
Defining the Disorder
By the time a patient ends up in my office, the eating disorder has generally been in place for months, if not years. It can take that long for a parent, spouse, or friend to realize that an eating disorder has taken root. It can take weeks or even months longer to convince the patient that treatment is needed, and then it can take weeks, months, or even years to find the right sort of treatment. In the meantime, of course, the eating disorder only grows stronger, as does the damage it causes.
The sooner an eating disorder is recognized, the easier it is to treat the problem. I know from experience, however, that individuals with eating disorders become very adept at hiding them. Even specialists can fail to see an eating disorder when it first presents itself. Definitions are a big part of the problem in detecting these disorders early on. At what point does being on a diet or eating too much become classified as a disorder? At what point does the desire for exercise cross over into an obsession? At what point does the act of taking refuge in 'comfort food' turn into a binge eating disorder? It's a fine line, and often the patient is well across it before anyone notices.
I recently started seeing a patient named Tessa. She's thirty-five and has a long treatment history. Before coming to see me, she had been treated by no less than eight different physicians and therapists specializing in eating disorders. According to Tessa, not one had the same eating disorder diagnosis for her and none were very effective in treating her. She was willing to give treatment one last try, which was why she was in my office.
At our first session, Tessa shared some of her early history. She was diagnosed with anorexia nervosa when she was fourteen, when she restricted her diet so much that she lost a significant amount of weight and stopped having her period. At that point, Tessa had all the major behavior patterns of the disease known as anorexia nervosa, as defined by the latest Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. These are the standard guidelines used by therapists, physicians, psychiatrists, psychologists, treatment programs, and others to define eating disorders. They're not perfect, but they're widely accepted as a workable way to ensure that everyone is defining the various eating disorders in more or less the same way.
In high school, Tessa showed all the classic signs of anorexia. She restricted her food intake so much that she had severe weight loss that was greater than 15 percent of the normal body weight for someone of her age and height. (Older definitions of anorexia nervosa said the weight loss had to be 25 percent or more—we're making some progress in diagnosing the disorder sooner.)
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