Episode 255: On this episode of Real Health Radio, it is a solo show and it is all about eating disorder recovery. I cover the many aspects that make up recovery when we truly want to get at all the ways that an eating disorder infiltrates one’s life
When talking about eating disorders, we typically split them into different categories. Often focusing on the differences between anorexia versus binge eating disorder. Or bulimia compared to orthorexia.
But despite the differences, all eating disorders are alike and are much more similar than they are different.
And this is especially true when thinking about eating disorder recovery. Regardless of the type of eating disorder, much of the recovery process is similar.
This week on Real Health Radio I’m looking at each of the eating disorders what is required as part of recovery.
As part of the episode I cover:
I hope you find it helpful. If there are others who you know would benefit from listening, please share it. It’s taken a lot of time and effort to put this together and I want as many people to hear it as possible.
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Chris Sandel: Welcome to Episode 255 of Real Health Radio. You can find the show notes and the links talked about as part of this episode at www.seven-health.com/255.
Before we get started, I just want to mention that I’m taking on new clients. I specialise in helping clients overcome eating disorders and disordered eating, chronic dieting, body dissatisfaction and poor body image, exercise compulsion and overexercising, and also helping clients to regain their periods. If you want help in any of these areas or you simply want support to improve your relationship with food and body and exercise, then please get in contact. You can head over to www.seven-health.com/help, and there you can read about how I work with clients and apply for a free initial chat. The address, again, is www.seven-health.com/help, and I’ll also include that in the show notes.
Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I’m a nutritionist that specialises in recovery from disordered eating and eating disorders, or really just helping anyone who has a messy relationship with food and body and exercise.
Today on the show, it’s a solo episode. I really enjoyed doing the recent solo episodes with Episode 249 on how to heal from trauma and then the AMA episode for the 250th show. Today’s episode is all about eating disorder recovery. This is something I have written about before; I’ve done specific articles on anorexia recovery and binge eating disorder recovery, and I plan to do articles on bulimia and orthorexia at some point this year, and then articles on other eating disorders after that.
But what I want to do today is look at eating disorder recovery as a whole. What does the process entail? With all eating disorders, there are differences and things that make them unique, which I’ll speak to and cover as part of this episode, but actually, what I’ve found from doing this work for such a long time now and through working with many different types of eating disorders is that there is a lot of overlap – that while, say, binge eating disorder and anorexia may appear different on the surface, they actually have a lot more common than they have differences.
If you listened to my conversation with Sasha Gorrell, which was Episode 246 of the podcast, this was actually something we chatted about. With all eating disorders, there are similarities, and the similarities that she pointed out are (1) there is a fear of the consequences of eating; (2) there is weight suppression, and this is a weight that is lower than this person was historically at; and (3) there are then behaviours that maintain the eating disorder.
With the clients I work with, especially for clients with long-standing eating disorders, it’s often that they present differently over time. At one point they would’ve received a diagnosis for binge eating disorder, and then there was a period where bulimia was occurring, and then later on it was anorexia, and then they go into a phase of more quasi-recovery that would be more likely diagnosed as orthorexia. This obviously isn’t the case with everyone, but it does happen more frequently than you’d probably imagine.
But in terms of the similarities that I talked about before with the fear of consequences of eating, with the weight suppression, with the behaviours that maintain the eating disorder, these have stayed throughout all of those different changes.
As a starting point, I think it would be useful to go through each of the eating disorders and look at the diagnostic criteria. A diagnosis is made using the criteria in the DSM-5, which is the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. I am not a psychiatrist, and it’s never my job to diagnose an eating disorder, but I can at least look at the criteria with a client to see if this describes their experience in any way.
I should add that I think there are huge limitations with the diagnostic criteria and it can be very black and white, but we can talk about this more broadly.
I then want to go through a list of symptoms that often occur because of an eating disorder. Some of these will be more common in one disorder over another, but it can be a good way of noticing if you are experiencing a couple of them, if you’re experiencing many of them.
Then we can look at the various aspects of recovery. If you’re doing recovery on your own, how you can assess how well you’re doing or how often you’re doing these certain things, or are you actually focusing on these certain areas. Or if you’re working with a provider, or thinking of working with a provider, you can assess how much of these are part of the recovery process on offer.
The show notes for this episode are going to be filled with lots of resources that I mention throughout the show, and some of those will be articles, some of them will be other podcasts. But I highly recommend checking out that page because there’s going to be a lot of information. It’s at www.seven-health.com/255.
00:05:10
Let’s start with looking at the different types of eating disorders, first starting with anorexia. Anorexia nervosa, often just shortened to anorexia, is a mental illness that is characterised by a preoccupation with restricting food and fear connected to weight.
To receive a diagnosis of anorexia, you need to meet the following criteria:
Now, there are different subtypes of anorexia, and I think it’s important to mention this, because while we have a stereotypical view of what anorexia looks like or what someone’s eating behaviours will be, it can be different to these narrow ideas.
The first subtype is the restricting type. This is the subtype that is the most stereotypical of anorexia, where someone consistently restricts without engaging in binge eating.
The next subtype is the binge-purge type, and this subtype is where someone has regular instances of binging and/or purging. Purging can include vomiting, laxatives, diuretics, enemas, or more commonly, compensatory exercise and fasting. These behaviours are used to deal with the supposed extra calories.
Then the third one is atypical anorexia, and this is where someone meets the criteria for anorexia except they aren’t living in what is considered a low body weight.
I want to linger on this final subtype, the atypical type, because it really points towards a bigger problem we have, both in society at large but also within the medical profession when we think about anorexia. While we have a bias of what anorexia or malnutrition looks like, the vast majority of people don’t match up to the stereotype in how they look. While I said there are three categories or subtypes of anorexia, there’s only officially two of them. There’s the restricting subtype and then the binge-purge subtype.
The atypical subtype falls under the category of ‘other specified feeding or eating disorder’, which is shortened to OSFED, which was previously known as ‘eating disorder not otherwise specified’. OSFED is the catch-all for those that meet some criteria for diagnosis but not all of them. In the case of anorexia, they meet the criteria except their weight isn’t low, or in the case of binge eating disorder or bulimia, the binge episodes or the binge-purge episodes are happening, but they’re not happening frequently enough.
Let me add some statistics to this to get a sense of why this is a problem. For example, there is a paper that I’ll link to in the show notes that’s called ‘Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women’. Very catchy title. They looked at the lifetime prevalence of an eating disorder by age 20. The prevalence of low weight anorexia was 0.8% of the population they studied, and the prevalence for atypical anorexia was 2.8% of the population. So atypical in this sample size is occurring more than three times the amount that the low weight anorexia is occurring. Really, if anything should be called atypical, it should be the low weight anorexia because it’s happening much less frequently.
There is another paper I’ll link to that is called ‘Prevalence of eating disorders over the 2000–2018 period: A systematic literature review’, and it shows that the eating disorder category with the highest prevalence is the EDNOS. They found that the weighted mean prevalence of this was 10.1% for females and 0.9% for males. By point of comparison, it put the prevalence of bulimia at 1.5% for females and 0.1% for males; for binge eating disorder, it was 2.3% for females and 0.3% for males, and anorexia at 1.4% for females and 0.2% for males. Meaning that the vast majority of people diagnosed with an eating disorder don’t match up to the criteria for a specific diagnosis and fall into this extra category.
As an aside, I would add that the figures for males with eating disorders that I just quoted I think are grossly underreporting what is really going on. Men are affected much more frequently than those statistics would make out, which is a topic for a whole other episode, but I felt that I needed to comment on it.
But really, the overarching message here is it’s important to realise that just because someone isn’t in a small or emaciated body, doesn’t mean that they aren’t suffering. Anorexia and eating disorders more generally affect people of all shapes and sizes, and someone shouldn’t have to reach some specific size or frequency of behaviour before we deem them as worthy of needing treatment.
It really is abhorrent that the thoughts and behaviours considered a disease in one person in one body size are considered a great plan or a solution for someone in a different body size.
It’s also important to note that even if you don’t meet the official diagnosis, you can still be struggling. As I’m demonstrating, rather than eating disorders being a binary issue where you either have one or you don’t, it’s more like a continuum. There’ll be many people who don’t meet the criteria for a diagnosable eating disorder and aren’t even assessed to meet the criteria for OSFED, but this doesn’t mean they are in the clear.
‘Disordered eating’ is the term that is used as a catch-all to describe the issues with food outside of an official diagnosis, and this is something I want you to keep in mind when I go through each of these eating disorders. Just because you may not match up to the official criteria, doesn’t mean that everything is fine. This is why looking at symptoms can be so useful and is what I’ll do after I go through the criteria.
A couple of things I want to mention, and this connects to the binge-purge form of anorexia. One is that I really think it’s important that we know that this is a category, because so often, clients will think that they can’t possibly have anorexia because they have episodes of binging. Well, just because there are episodes of binging, doesn’t rule out anorexia.
The same thoughts can occur for those who meet the criteria for the restricting subtype. They can think that they are eating food. It’s not that they don’t eat any food, and to them it feels like they eat a lot of food, so again, they rationalise, “I can’t possibly have anorexia because I don’t match up to what I think is the stereotypical view of anorexia.”
The other thing I would add is that often people start out at the restrictive subtype, but with time it becomes the binge-purge subtype, where they can’t restrict in the way that they could before. For example, this is when exercise then starts to increase, often drastically so, to try and compensate.
This can often be the point when someone seeks treatment, because now that binge is occurring, it’s finally seen as a problem. Or even if treatment isn’t sought at this point, it’s still thought of as a defining or a watershed moment, that this is when they started seeing it as a problem – or this is the point that for them proves that they don’t have anorexia because they are really a binge eater, and the binge eating is the problem. But again, it’s worth knowing that just because binges occur, doesn’t mean you no longer have anorexia.
00:13:30
The next eating disorder I want to look at is binge eating disorder, often shortened to BED. To receive a diagnosis, you need to meet the following criteria:
I need to add some more colour and explanation to the above. As a society, we use the word ‘binge’ in connection to a wide variety of experiences with food, and it’s often used quite flippantly when describing eating a chocolate bar or a piece of cake. But in the case of binge eating disorder, the word has a very different meaning and is part of a very different experience. It’s not simply a case of having an occasional time of eating past the point of fullness. It is the experience of losing control when eating and having your relationship with food completely changed over time because of this.
Food can become adversarial, where you try your best to avoid it, but it also can be the thing that is turned to, often unintentionally, as a way to deal with difficult feelings or difficult situations. It can be very upsetting and maddening in terms of the powerlessness that one can begin to feel around food, and no matter how much willpower one applies or how many times you tell yourself ‘never again’, it reoccurs. And even with all the shame or the guilt or the disgust or the physical discomfort from the experience and the aftermath of that binge, it’s still not enough to prevent it from happening again.
A big reason that I see this is happening is because I feel there is a mix-up between what is the driver and what is the symptom, or mistaking the symptom for where the problem really lies. For example, everyone believes that the binges are the problem – that “If I can simply stop the binges by learning how to control myself, then the problem will fix.” But the binge is actually the symptom.
The real driver is restriction, dieting, or dieting mentality, and eating large amounts of food is the body’s response to this restriction. This is known as the diet-binge cycle, where you restrict or diet, it then becomes too much and you have a binge, you feel terrible and decide you need to restrict and diet again, and the cycle continues.
A common response to this information when I mention this to clients is, “But I’m not restricting.” I would say given the world that we live in, this makes sense, because restriction has become so encouraged and normalised that we’ve stopped even thinking of it as restriction. Restrictive practices are rebranded as health promoting and biohacking, and we can add a moralistic tone to them where you’re a ‘good’ or a virtuous person for pursuing them. Diet culture is so ubiquitous that we just don’t see it.
With every client that I work with with binge eating disorder, restriction is a central part of the problem, even if in the beginning the client is unable to see that this is true. This isn’t to say that it is only about restriction. There can be many other components connected to this, and most often there are, and these all need to be worked on. These are things that I’m going to go through when we get to all the things that are part of the recovery process. But I am yet to see a case of binge eating disorder where restriction wasn’t present and where it wasn’t having a primary role in driving it.
I’ve actually done a whole podcast on restriction, which, if you haven’t listened to, I’d highly suggest checking out, because it goes way beyond what most people think of as restriction and can be rather enlightening. It’s Episode 214 of the show, and I’ll add it to the show notes.
Now back to the criteria for binge eating disorder. Criteria 4 states that the binge eating occurs on average at least once a week for 3 months. I wouldn’t get too hung up on this and think that it can be happening less frequently and obviously still be a problem. So even if this would mean that someone falls into the disordered eating category or the OFSED category instead of getting an official diagnosis of binge eating disorder, this can still be thought about as serious.
Criteria 5 states that the binge eating is not associated with recurrent use of inappropriate compensatory behaviours (for example, purging) and does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, or avoidant-restrictive food intake disorder. I talked earlier about atypical anorexia, and I think that many people who are diagnosed with binge eating disorder actually meet the criteria for atypical anorexia, binge-purge subtype, so combining those two subtypes together. The only reason they don’t get this diagnosis is because of our weight bias and the fear we have in society of weight gain. This combined with the distress caused by the binges and the focus then being placed on them.
In some ways, it is semantics. If the focus is on recovery, the actual label doesn’t matter. But in many ways it does matter, because often the way that treatment is structured for binge eating disorder is different than it is for anorexia recovery. And with binge eating disorder treatment, the binges are seen as the problem rather than the symptom.
I would also say that for the individual, they would think differently about the issue if there was a diagnosis of anorexia rather than binge eating disorder, largely because of the stereotype connected with binge eating disorder versus with anorexia.
So whenever I look at the statistic around eating disorders and see that binge eating disorder, outside of OFSED, is the one diagnosed most often, I’m always aware of the biases that are playing into this.
The final thing I want to mention is that binges can be both intentional and unintentional, where someone plans to have a binge and goes and buys food in preparation for this, or where someone starts eating and then it turns into a binge. Interestingly, in this second category with the intentional binge, there’s often some imagined line that has been crossed that leads to the binge. A meal has been eaten or is being eaten, and then there’s the realisation that they have eaten a certain amount of food and yet are still hungry, or are still craving more or are craving something different, and it can be at this point that the eating becomes more rapid, and this is when the loss of control occurs.
There is obviously much more to binge eating disorder than I’ve just covered here. I wrote more about it in the article called ‘Do I Have Binge Eating disorder?’ Once again, I will link to that in the show notes.
00:21:31
The next eating disorder is bulimia nervosa, or just shortened to bulimia, and the diagnostic criteria for it is:
1.Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following: one, eating in a discrete period of time (e.g., within a 2-hour window) an amount of food that is definitely larger than what most people would eat during a similar period of time and under similar circumstances; two, a lack of control over eating during the episode (e.g., a feeling that you cannot stop eating or control what or how much you are eating);
2.Recurrent inappropriate compensatory behaviours to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics and other medications, fasting, or excessive exercise;
3. The binge eating and inappropriate compensatory behaviour both occur, on average, at least once a week for 3 months;
4. Self-evaluation is unduly influenced by body shape and weight;
5. Binging and purging does not occur exclusively during episodes of behaviour that would be common in those with anorexia nervosa.
Some things I want to mention with this. Bulimia, like other eating disorders, has a stereotype associated with it, and many people believe that the purging means vomiting, and that without vomiting, it can’t be bulimia. But as the criteria shows, this is not the case.
I also think that it is interesting to think of the criteria for bulimia and see who similar it is to anorexia, especially if someone is using exercise as their means of compensation, which, with the clients I work with, is so common. If someone is using exercise excessively and having times of binging, what is the difference between anorexia binge-purge subtype versus bulimia nervosa? The same can even be true if someone is using vomiting as their means of purging. Why pick bulimia as the diagnosis over anorexia?
I suspect that someone’s weight would be the determiner here, and if someone is in a low weight body, they would be diagnosed with anorexia binge-purge subtype, and if their weight isn’t low enough, they’ll be diagnosed with bulimia nervosa. Again, this can be seen as just semantics because recovery is recovery and what does a label mean, but I also think that for many people, the diagnosis they get is in part due to weight bias, and the stereotypical ideas about what certain eating disorders look like. But I’m also mentioning this just to show the overlap between eating disorders and how similar they all are.
The third criteria states that binge eating and the inappropriate compensatory behaviours both occur on average at least once a week for 3 months, but again, I don’t think this should be something to get hung up about. There can be a lot of damage still occurring even if it’s happening less frequently than this.
My comments earlier about restriction with binge eating disorder are also true with bulimia nervosa. With the clients that I work with, it is at the heart of the bulimia and why it’s occurring. In a sense, binge eating disorder and bulimia are very similar; simply with binge eating disorder, the compensatory component is missing. And I would say it’s not actually missing, because I think there is a lot of compensation that is still occurring for those with binge eating disorder with the restriction, with exercise. So again, I think there is probably a lot of similarities between these two, and more similarities than most would imagine.
00:25:12
The next eating disorder category is avoidant-restrictive food intake disorder, or ARFID. In the DSM-4 (this was the version before the most recent one), it was referred to as selective eating disorder, but it was then changed in the DSM-5 to ARFID. The diagnosis criteria:
There are three subtypes of ARFID, and these are unofficial subtypes in the way they are for anorexia, but they’ve been suggested based on the scientific literature. This is actually something that Lauren Muhlheim goes into detail in our conversation. We talked about ARFID during our podcast episode, and it’s Episode 232 of the podcast. I’ll link to that again in the show notes.
The first subtype is known as the sensory subtype or the avoidant subtype, and this is about an individual avoiding certain foods because of the sensitivity to it. This could be because of smell or texture or intensity of taste or appearance or colour. This is common with autism spectrum disorders or other developmental or sensory processing experiences.
The second subtype is lack of interest. These individuals have low appetite and lack the usual drive to eat. This isn’t about restriction or a temporary situation, but appears to be a permanent state connected to various hormones and processes within the body.
The final subtype is fear of adverse consequences. This can be fear of swallowing or choking or nausea or vomiting or pain, and often this is because there was a point where this occurred, so a fear develops of it happening again.
In this third category about fear of adverse consequences, we could also add the fear of health implications. This would then capture orthorexia nervosa, or just orthorexia, because at this stage orthorexia is an eating disorder that doesn’t actually appear separately in the DSM-5. Orthorexia is an obsession with eating only ‘clean’ or ‘healthy’ or ‘pure’ foods to achieve ideal health. The usual trajectory with this is that more and more foods are removed from the diet because they are considered unhealthy, and this typically leads to weight loss and nutritional deficiencies and actually pushes someone further away from genuine health.
Like I commented numerous times before, there can be overlap with other eating disorders with orthorexia or ARFID more generally. While Criteria 3 mentions that this isn’t focused on weight or shape, this can become an issue even if it wasn’t a primary concern when it started. With time, there are concerns about body weight and size or fear of weight gain or negativity about fatness or negative body image or preferences for less calorie-dense foods. This may have always been there but rises much more to the surface when someone is contemplating recovery or simply deviating from their current way of eating.
00:29:40
The final eating disorder category that I want to mention is the one that I’ve already touched on, which is other specified feeding and eating disorder, which is OSFED. This is the catch-all category for other eating disorders that don’t meet up with the specifics of the criteria that I’ve gone through for all the other eating disorders.
Some examples of this are atypical anorexia nervosa, so an individual meets the criteria in terms of the restrictive behaviours and other symptoms, but they’re not at a low weight; bulimia nervosa, where it’s low frequency or limited duration, so an individual meets the criteria but engages in binging or purging behaviours at a lower frequency or for a limited time period; binge eating disorder where it’s low frequency or limited duration, so it’s just not happening as often as the criteria makes out. You could have purging disorder, where a person has recurring episodes of purging without binge eating; night eating syndrome, so a person has recurrent episodes of eating large amounts of food at nighttime.
And then there can be combinations, which is actually very common. There is some binge eating, then there’s some purging, there is a fear about the healthiness of food, then there are stretches where their eating is more normal or is more diet-like and then stretches where it becomes much more extreme again. On paper, this may seem less severe, but in actuality it’s still having a huge toll on the body and is taking up an inordinate amount of time and worry in someone’s life.
So those are all the eating disorders and their diagnostic criteria. What I think is often more helpful than just looking at this is also looking at the symptoms that arise because of how someone is engaging with and relating with food. Something can look like it’s low frequency or more minimal and yet it’s actually having a huge impact when we look at the symptoms that are occurring because of it.
In this section, I’ve put all the symptoms together rather than listing them out for the separate eating disorders, and the main reason for this is that probably 80% of them or more than that are symptoms that occur with each of the eating disorders, irrespective of which one it is. There are going to be symptoms that are opposite, which is then likely to occur in one and not the other, but as I said, it makes more sense to list all of these together.
00:32:11
So, physical symptoms. Feeling cold and increased sensitivity to the cold, with the need to wear more layers. This can lead to pain and symptoms of Reynaud’s disease. You can have numbness and tingling in the hands, feet, and other extremities.
Poor sleep with difficulty falling asleep, staying asleep. Increased nightmares, night sweats, and restlessness. Increased digestive upset – gas, bloating, constipation, abdominal pain, loose stools, undigested food in the stools, acid reflux, or delayed stomach emptying.
Decreased pulse, heart palpitations or irregular heartbeat. Low blood pressure, leading to the occurrence of dizziness and feeling faint, especially when getting up or with exercise. This, when it’s bad, can lead to blackouts.
Hypoglycaemia, or low blood sugar. This can also lead to dizziness and feeling faint, as well as nausea. In extreme circumstances, this can actually be deadly.
Decreased metabolic rate, decreased libido, often with menstrual cycles becoming irregular or stopping altogether in women or lack of erections or erectile dysfunction in men. Vaginal atrophy, leading to pain with sex, and vaginal itchiness or dryness. Brittle hair, nails, skin, and where these grow and repair much more slowly.
Poor dental and gum health. Increased cravings for salt. Increased desire for hot beverages, especially caffeinated drinks. Increased frequency and urgency of urination.
Muscle cramps and pain. This can counterintuitively be worse with rest or with the cessation of exercise, at least in the short term. Decreased training performance or ability to exercise, although with something like walking, this can often be overridden, and often in the beginning, even if the body is being undernourished, exercise performance can actually increase. But as time goes on, this stops.
Oedema and swelling. This can happen all over the body, but commonly in the ankles and feet and legs and arms, and then in the face, under the chin and the cheeks and around the eyes. Cuts are slow to heal. Bruising occurs more often and takes longer to heal. There’s an increased incidence of bone fractures or injuries. elevated carotene in the blood, which can lead to yellowing of the skin. There can be immune system changes. For some, this means recurrent infections, and for others this means never getting sick.
Anaemia or low amounts of red blood cells. These are the ones that carry the oxygen. This can lead to lower energy, but it can also lead to someone feeling tired and wired. There can be shortness of breath, difficulty swallowing. Lanugo, which is fine hair that develops over the body. Increased pain threshold, so you become more numb to physical body signals.
There can be scars on the knuckles or on the hands. Sore throat and canker sores or ulcers in the mouth. And feeling uncomfortably full after eating, which can happen both with small amounts of food or after a binge.
There can be physical changes. There can be reduction in heart size, there can be brain atrophy, there can be bone density reduction, there can be reduction in the actual size and capacity of the bladder, there can be electrolyte imbalance.
00:35:42
In terms of mental and emotional symptoms, there can be increased neuroses, like depression and anxiety and hypochondria and hysteria. This can lead to suicidal ideation. Increased irritability and impatience. Increased paranoia and defensiveness. Inflexibility in thinking. Feeling like you’re not sick enough.
Increased food thoughts and preoccupation, especially around calories and fat grams and carbohydrates and healthy eating. This can be obsessive and also anxiety-provoking. There could be a lack of interest in food. There can be a hyperawareness of food and movement and noticing what others are eating, triggered by comments of what others are doing with exercising or dieting.
There can be fear of eating too much and of calorie-dense foods and supposedly unhealthy foods, a fear of texture or smell or appearance of certain foods, a fear of weight gain, of feeling fat; regret and guilt because of eating. Eating becomes highly emotional, whether that means incredibly difficult and challenging as well as eating being so prized and defended and the highlight of someone’s day. There can be dreams about food. Fear of vomiting. Fear of stillness and stopping moving.
Difficulty focusing and concentrating, although in the beginning, the opposite can be true. A loss of ambition. Feeling more alone and shut off, which in reality can also be the case, where someone is isolating themselves more of the time. Indecisiveness with food choices, but with decisions in general.
There can be obsession with weight and body checking. Sensitivity to noise and crowds. Many clients, when we look into it, are Highly Sensitive People (HSPs), and this can make this worse. The dulling of senses and emotions and feeling numb. Increased incidence of disassociation, often as a coping mechanism to deal with exercise or the difficulties of life. Body dysmorphia and seeing their body differently from how it is in reality.
00:37:51
And then in terms of behavioural symptoms, there can be increased lengths of mealtimes, eating more slowly, eating foods in a specific order, or other rules around eating (i.e., using specific cutlery or plates or eating at an exact time). Times of increased speed of eating and episodes of binge eating, especially when eating food one would normally avoid.
Chewing and spitting out of food or regular use of chewing gum or low-calorie sweets. Vomiting, taking laxatives or diuretics, enemas, and/or fasting. Hiding food and eating secretly. Avoiding eating in front of others. Using dietary supplements and herbal products for weight loss.
Cooking food for others, but without eating yourself. A focus on trying to take care of everyone else instead of yourself. Increased interest in preparing food, reading recipes, buying cookbooks, and watching food-based TV programmes. Eating a limited number of foods with fear of deviating from this list.
A rigid and excessive exercise routine that causes distress when you try and change it. Increased walking, housework, standing, fidgeting, and pacing. Favouring occupations that allow for movement. Withdrawal from friends and activities that used to be of interest. Reluctance to participate in activities where the body will be viewed by others (i.e., swimming). This is true even if someone’s body meets up to society’s standards and they supposedly have nothing to hide.
Engaging in self-harm. Frequently dieting. Possessiveness and hoarding – cookbooks or recipes or keeping the fridge completely stocked with food. Also hoarding non-food items, so plastic bands or magazines or cleaning items, etc.
Kleptomania, which is the urge to steal. This can be food items, but it can be non-food stuff as well. Eating food out of bins or food that has been thrown away. Compulsive spending or being extremely frugal. These are opposite ends of the spectrum, but both can occur. Prone to forming strong habitual habits. Increased OCD or OCD-like behaviour, and increased ability to lie, particularly in connection with food. This isn’t always the case, but if someone isn’t ready to give up the disorder, this can be occurring.
That is a very long list of symptoms that can be common with eating disorders, and I guess when you hear that list, how much does that match up with your own experience? How many of those symptoms are things that you are currently experiencing right now?
I now want to look at the different aspects of the recovery process. These are all things that I work on with clients, and for some it will be more of one or more of some than others, but this is looking at recovery broadly and all the aspects that are interconnected.
00:40:50
The first area is nutritional rehabilitation. So many of the symptoms that are connected to eating disorders are due to malnutrition. As part of the things that Sasha Gorrell listed as commonalities with eating disorders, weight suppression is one of them, and weight suppression from where the body historically was.
When the body is getting less energy compared to what it needs, it has to make cuts. No organ or body system is spared from this, and as a result, symptoms start to occur, like the long list that I just read out. I’ve done articles looking at relative energy deficiency in sport (RED-S), on hypothalamic amenorrhea (HA), and fairly recently did one on bone health. These all look at the processes by which reduced energy impacts the body.
I’ve also done a very detailed podcast on the Minnesota Starvation Experiment that really demonstrates how energy depletion affects every part of the body, and so many of the symptoms that the men experienced as part of this experiment then match up to eating disorders. I’ll link to those articles and the podcast in the show notes.
One area that is affected by malnutrition is the brain. This leads to changes in thoughts and belief, and personality can also change. Sadly, while this is occurring, it can be hard to grasp how much this change has occurred. You can lack the awareness to truly appreciate how things have changed, and it can feel like “This is just me” or “This is what I truly believe or want.” But once out the other side, it is amazing how these beliefs and thoughts change and where someone can finally see how much this was being driven by the insufficient energy. These brain changes are something I touch on in the Minnesota Starvation Experiment because it was one of the things they looked at as part of that, but I’ve also done a whole separate episode on how the brain is affected by restriction and being in a low energy state. I’ll add that to the show notes as well.
I need to stress that nutritional rehabilitation is important in all eating disorders, irrespective of the body that someone is in. It can be easy to believe that this is only relevant if you are visibly emaciated. Interestingly, as a demonstration of just how much the brain is affected by energy depletion, even for clients whom I work with who do match up to that stereotype of being emaciated, and even when they can acknowledge that their body looks too thin, they still struggle with the idea that they could really need more food.
In my previous conversation with Fiona Willer, we talked about malnutrition in higher weight bodies and how this is definitely a thing and can be hugely damaging to the functioning of the body. Someone can still be experiencing the same symptoms as someone in a much lower weight body, even if their body doesn’t match up to the stereotype of what malnutrition or a malnourished body looks like. Again, I’ll link to the Fiona Willer episode in the show notes.
I also want to add that this is relevant even if binges are occurring. There can be this false belief that if binges are occurring, then the body must be getting what it needs, or believing that it’s even getting more than what it needs and nutritional rehabilitation is therefore irrelevant. But as I mentioned earlier, restriction is a part of the picture for all eating disorders, and this is true even if binges are occurring.
The goal of nutritional rehabilitation is to get the body out of the depleted state it is in and provide it with the resources it needs to repair. This means not just meeting your energy demands for today, but also paying off all the energy debt that has accrued, because obviously, there is damage that occurs from being in a malnourished state for an extended amount of time.
What this nutritional rehabilitation looks like will depend on someone’s current situation, and part of this, as I said, relates to how long it’s been going on for and how depleted the body is. But it also relates to the ability that someone has to take in more energy and to move out of this place.
There can be psychological reasons why someone is increasing their intake at a slower pace – that it just feels too overwhelming to make changes too quickly. But there can also be physical reasons why this is occurring, too. I’ve done articles before on how digestion, for example, can be affected by recovery, because if it has slowed down and there is slowed gastric emptying, it can be a real challenge to take in more food quickly. It may need to be going at a slower pace.
I’m not going to give a specific plan here for what nutritional rehabilitation looks like because there isn’t one plan that someone has to follow, but I do want to just stress how important it is. And once again, this is something I cover as part of the Minnesota Starvation Experiment, where I go through the recovery the men experienced and what this looked like for them.
While you may not want to hear this, this is not going to be a quick fix. This repair takes time, and as much as people want to avoid it, it is completely necessary. If the body is given the resources and this happens for long enough time, it truly can heal.
00:46:16
The next area is brain repair and neural rewiring. As I just mentioned, malnutrition affects all parts of the body, and the brain is no exception. Brain matter actually shrinks, and these physical changes then lead to changes in personality and beliefs and thoughts and behaviours. To reverse these changes, increased energy intake needs to occur. This extra energy then facilitates that recovery, so a big part of nutritional rehabilitation that I just covered is helping here.
But in addition to the energy intake, there also needs to be a learning of new habits or patterns of behaviour at the brain level. This is known as neural rewiring. There’s an oft-used phrase that ‘cells that fire together, wire together’. What this means is that the more you do something, the more it becomes ingrained. This is definitely the case with eating disorders. The more you’ve acted on behaviours connected to eating patterns and rituals or exercise and movement regimes, the more these become normalised and habituated.
This is a topic I touched on a lot in my conversation with Sasha Gorrell, whom I referenced at the start of the podcast. And if we think of eating disorders being an anxiety disorder, then the approach for dealing with this is exposure. It is doing things that are in support of recovery, even though they are challenging. They’re challenging because the brain has been wired based on repetition and we’re now doing something different.
Based on the conversation with Sasha, I wrote a blog post all about anxiety and behaviour change in this process of neural rewiring. I’ll link to that in the show notes. It’s also a topic that is covered in Tabitha Farrar’s excellent book, Rehabilitate, Rewire, Recover!. This book is fairly directed towards anorexia recovery, but many of the suggestions are fairly universal for all eating disorder recovery.
I’ve also made reference to my conversation with Lauren Muhlheim, where we talked about ARFID and the three different types of ARFID. We actually go through each of the different recovery processes and how they look different and how these are approached, and part of this is then connected to the neural rewiring and how the connection to food and food behaviours is changed.
I think it’s important to understand this neural rewiring process because when in the midst of an eating disorder, it can feel like things are permanent – that “These are my go-to ways of behaving and these are my go-to ways of thinking, and they’re just so automatic and I don’t ever see them changing.” I want people to know that change can and does occur, but, like I mentioned with nutritional rehabilitation, it is slow. These changes to the brain can take a lot longer than you would like.
This is true of the physical repair to the brain as well as the neural rewiring. In the beginning, it is doing things that feel uncomfortable, where it feels like there is little or no improvement, but with enough time this does then change.
00:49:26
One of the biggest areas that needs neural rewiring is connected to food. This is the next area, and it’s challenging food rules and food fears. As I talked about in the very beginning, one commonality that all eating disorders have is fears about the consequences of eating. This fear changes how food is seen. It is seen as a threat, and much like when we see a snake or a spider, it sets off the body’s stress response. Eating can become a terrifying experience, where you want to find the foods that you label as safe to minimise this discomfort.
As a way of trying to mitigate this fear, certain rules and rituals arise. This could be connected to the types of food, the order of eating, the timing of meals, the setting, the types of plates or bowls or utensils. These are behaviours that are a way to try and soothe the uncomfortableness of mealtimes. Recovery is therefore about rewiring the body’s response to food and teaching it that what it currently fears and leads to a stress response is actually safe and does not warrant this kind of response. This is done by challenging those food fears and food rules.
Depending on the type of eating disorder and the types of rules and rituals that have developed, it will affect how this looks. For example, if there are rules about certain foods that are off limits, it would be bringing these foods back in. If there are rules about not eating before a certain time or after a certain time, it would be doing the opposite to this rule. If there are rules about certain plates or cutlery, it would be changing and using different utensils.
And sometimes it’s not about rules but about certain fears. For example, “If I reach a certain level of fullness, this is what always leads to a binge or leads to a purge”, or “I fear to keep certain foods in the house or buying certain foods as a multipack because I worry about having them around in the house.” Again, in Tabitha Farrar’s Rehabilitate, Rewire, Recover!, she lists many of the different rules. I said earlier, this book is more specific for anorexia recovery, but many are fairly universal and apply to most or all eating disorders.
Whatever the rule is or the fear is, it’s about working to overcome this. This approach will vary. Sometimes it is doing the proverbial ripping the Band-Aid off, and by directly challenging the fear and doing so repeatedly, it then dissipates and is no longer a challenge. Other times, it’s about small changes and working their way up, so looking at the problem and breaking it down into smaller chunks.
In other circumstances, it may take working on the issue in a more indirect way. For example, binges may be associated with eating a certain food, but actually, when we dig in deeper, this is occurring because of the restriction that is happening beforehand, and the times that someone eats that particular food, they are very, very hungry. So whenever the supposedly triggering food is eaten, there is this build-up and chain of events that goes back many hours or even days.
Then to deal with this fear, we focus on the aspects leading up to this point, and then when someone has that previously triggering food, because they are in a different state, it has a different effect and it doesn’t lead to a binge.
All of this is just to say that challenging food and food rules and food fears can be done in a variety of ways depending on what is most appropriate for the situation. And by doing this, it can help with both nutritional rehabilitation and the neural rewiring process.
00:53:17
The next area to look at is exercise and movement. Once again, this can be having an impact on both nutritional rehabilitation and neural rewiring. For many clients, exercise compulsion and overexercise are a part of their eating disorder. Often this can be about managing weight or as a way of compensating for eating, or because of the supposed health benefits, or as a way of managing anxiety. This can take many different forms. It can be HIIT classes, boot camps, spinning, yoga, running, walking, cycling, triathlons, rock climbing, marathons, weight training, bodybuilding or physique competitions.
I would also add that other forms of movement are also worth noticing; for example, many clients are spending huge amounts of time cleaning each day. Even though this may not feel like exercise, it’s clearly using up a lot of energy and is also a compulsive behaviour that they feel compelled to do.
Despite how exercise is talked about, it isn’t always this positive thing for health. To benefit from exercise, the body needs adequate calories, adequate rest and repair, and with the clients I’m seeing, these other components are missing – so exercise turns from something that can be healthy into something that is further depleting the body.
Our relationship with exercise is equally important. There’s a difference between genuine enjoyment compared to compulsion or needing to exercise to change the body or make up for the food that was eaten.
For recovery, this means a change in exercise and movement habits and also a change in the relationship to exercise and movement. Like I talked about with challenging food rules, this can look different depending on the situation. It may mean a reduction in the total amount that is being done. It may mean changing from one form to another, maybe something that is gentler. It also might mean a total cessation, at least for some length of time. I know for so many clients, it can be hard to go back to a form of exercise that they did as part of their disorder. There’s just too much association with that form of exercise.
This doesn’t mean that there isn’t some pull to go back to that exercise. Often there is. But when they start to do it, they notice that it just doesn’t work for them. Interestingly, what I’ve noticed with clients is that this pull does disappear with time. For example, there is this desire to get back into running, they are making changes and having a break, but there’s still this belief that this is temporary and they’re just counting down the time until they can get back into it.
But at some point this urge disappears. There’s a realisation of how destructive it was or how they didn’t actually enjoy it as much as they were telling themselves. When they do get back into movement or exercise, it is doing new things that aren’t associated with their eating disorder or rediscovering ways of moving that they did as a kid or before the disorder happened that had then dropped away.
Obviously, this isn’t the case with everyone, and for some they do find a way to go back into the exercise that was associated with their disorder. But to do this, they learn to have a different relationship with this exercise.
As part of the neural rewiring piece and breaking free of the compulsive nature, I really focus with clients on building psychological flexibility. Maybe they start out slowly, where it’s once a week, and then it becomes twice a week, and then it’s three times a week. This takes a long time to build up, so there’s real intention of not rushing this. But when they are doing it say three days a week, rather than doing this all the time, can they still mix it up? Can they then have times of doing it twice a week or once a week or having weeks off? Really constantly proving to themselves that they are in the driving seat.
Over the long term, this might not be necessary to keep up with this kind of intentionality and maybe just starts to happen naturally because of the busyness of life and how someone is feeling, but in the early years of recovery or after recovery, I think it’s important to really understand just how fragile and precarious this time is and really needing to constantly build that resilience and that psychological flexibility.
00:57:47
The next area to look at, or more accurately, skill to learn, is that of urge surfing. The term ‘urge surfing’ was developed by the psychologist Dr Alan Marlatt and was originally used for drug and alcohol addiction. An urge is an impulse to engage in a particular habit, and with eating disorders, this could be an urge to restrict or to purge or to exercise or to binge.
The reason this is referred to as ‘urge surfing’ is that urges are like waves in that they rise in intensity, they then peak, and eventually crash, all of their own accord. For example, after eating a meal, there could be an urge to do some compensatory behaviour. This urge rises up and can feel like it is all-consuming unless you give in to this urge. But if you avoid acting on this urge, with enough time, the wave of desire to do this will come down on its own.
Now, it may take an hour, it may take many hours to come down, so it’s not instantaneous. And it’s not that the urge comes down to zero. There may be still some baseline pull towards that behaviour. But the intensity is reduced and comes back to what we can think of as baseline for the current state that the body is in.
This is a practice. Just becoming aware of this concept isn’t enough. A big part of urge surfing and making it work is having an open and curious and non-judgmental mindset, because the time it takes for the urge to pass is connected to the response that someone has when that rises up.
For example, it’s said that the lifespan of an emotion is 90 seconds, and that is how long it takes to flush out the chemicals in the body that created that emotion. But I know for myself, emotions typically last much longer than this, and that’s because we usually do things to keep these emotions alive. And this is true for both positive or negative emotions. We use our thoughts and our actions to keep that emotion alive, and sometimes this is a wonderful thing, like we get to experience longer periods of joy or excitement or contentment or other pleasant emotions, but it also means that emotions that we label as negative emotions – anger and rage and overwhelm and embarrassment or shame or really any of the negative emotions – also last for a longer period too.
I would say that I believe it is highly unrealistic to think that as humans, any time a negative emotion rises up, we believe that within 90 seconds we will be past it. I think that is an absolute pipedream. But I do think it is worth recognising our role in perpetuating these states.
How does urge surfing work? How do you do it? I can give a very simple example. When an urge rises up, you stop and you notice the sensations in the body. Where are these sensations located in the body? What do these sensations feel like? Does it feel like pressure, tingling, warmth or coolness? How much space do these take up in this place in your body? Could you draw a line or an outline around the place where the sensations are felt? Are there any movement to these sensations? Some people tend to associate sensations with colour or with temperature. Can you check to notice, are there any colours or temperatures associated with these sensations? You can then bring your attention to the breath and keep going with building this level of awareness about this experience.
That’s just a very short example; that’s not how urge surfing has to be done. There are many different ways. But you’re doing all of this from a place of non-judgment and simply being a witness to the experience and curious about this experience.
While I’m talking here specifically about urge surfing, I think this is simply one part of really the bigger picture of mindfulness and becoming aware of our inner experience, whether that be thoughts or feelings or sensations. It’s learning the ability to be present, to be aware with what we’re doing and our immediate surroundings.
There are lots of different ways of doing this. I’m a big advocate of acceptance and commitment therapy, or ACT. I don’t necessarily know if this is the best way, but it is simply the one that I know best. I highly recommend Russ Harris’s book The Happiness Trap, as it is a great resource on this topic.
Emotion coaching is also part of this and is something that I talked about with Adele Lafrance, at least in the earlier part of the conversation we had together. She is the co-developer of emotion-focused treatment modalities, one of these being emotion-focused family therapy. A big part of this approach is emotion coaching, and her work is based on or drawn from the work of the Gottman Institute, which was founded by Drs John and Julie Gottman. Their work is very much aimed at parents and helping parents to help with emotion coaching with their children. With Adele’s work, it is similar; she’s also helping parents to emotion coach their children.
But even as an adult, I can read the material, I can read John Gottman’s book – I think it’s John and Julie Gottman’s book about emotional coaching for children – and it can be completely relevant for me. In a sense, I play the role of both parent and child. Where my emotions arise, I’m helping to guide myself kindly and compassionately to become aware of my sensations and my emotions, where I can validate my own feelings and see if I can label the emotion accurately and then figure out how to deal with this situation constructively.
Using an emotion wheel with this can be a helpful starting place to remind you of all the different kinds of emotions. Brene Brown’s book Atlas of the Heart is also really helpful here. It goes through 30 or 40 different emotions and explains them in detail.
Understanding of polyvagal theory I think can also really be helpful with this mindfulness piece. I cover this in my podcast with Deb Dana. She’s one of the people who has written most extensively on this topic and actually written in a way that is very useful for both practitioners and for the lay public. Again, I’ll link to all of these things I just referenced in the show notes.
01:04:36
Very much connected to this idea of mindfulness is compassion, particularly self-compassion. Recovery is challenging, and it is messy. The body responds in ways that you would like it not to. I think one of the best and biggest antidotes for this is self-compassion. Dr Kristin Neff is a pioneer in the field of self-compassion research and has probably studied it more than anyone else, and she defines self-compassion as having three main characteristics.
One is self-kindness instead of self-judgment – recognising that we are imperfect, we’ll make mistakes and go through different experiences, and in these moments we need to treat ourselves with kindness. Two, common humanity instead of isolation – recognising that suffering is part of being human and is a shared experience, not something that is only happening to you. And three, mindfulness instead of overidentification – recognising how our thoughts and feelings actually are so they are not suppressed nor exaggerated.
Like urge surfing, self-compassion is a skill. It’s something that you can learn to do. With most clients, I actually start by looking at the Fears of Compassion scale that was developed by Paul Gilbert. It looks at fears connected to giving compassion to others, receiving compassion from others, and receiving compassion from ourselves. This was a scale that I learned from Josie Geller, whom I had on the podcast and I’ll link to in the show notes. She’s done a huge amount of research looking at recovery and compassion and how compassion is correlated with recovery but is also a predictor in the likely success of recovery.
But I want to add again that our level of self-compassion isn’t fixed, and it is a skill that can be learned and can be increased.
In the area of compassion, I want to mention two other people who I think are fantastic. One is Tara Brach. She’s written many books on the topic. She’s also done many meditations on it. Her style is a little different to Kristin Neff, and I tend to find that clients prefer one over the other, but which one varies. So if you start with one of them and it doesn’t resonate, try the other, or just try them both and see what you notice.
The other person is Beverly Engel, who has also been a guest on the podcast. She has a background in different forms of abuse. For those who have suffered abuse, they can have a particularly difficult time with compassion, so this can be helpful if this is your background, because Beverly’s work really speaks to and deals with aspects that are specifically connected to this.
The final piece that is connected here is acceptance, and I do think there is an overlap between all these ideas of urge surfing and mindfulness and compassion and acceptance. I wrote a blog post recently all about acceptance and why, like self-compassion, it really is a key to recovery. I will link to all of those things in the show notes.
01:07:41
The final part I want to mention connected to this section on mindfulness and emotions and self-compassion is the importance of developing healthy coping skills. While eating disorders can have many reasons for forming and can serve many functions, one function is as a coping mechanism.
People keep up behaviours that are serving them in some way. Irrespective of how much pain or damage a behaviour may cause, if it’s being kept up, there is some positive intent and/or positive outcome because of it. Because of this, I’m a big believer that people keep their problems for a reason, and in a sense these aren’t actually problems but they are solutions. This doesn’t mean that it is the best solution, but at least at this time, it’s the best solution that someone has come up with.
The goal with recovery is to understand, what is the eating disorder doing for you? What benefit is it providing? What need is it meeting? Some examples for this are “It allows me to deal with anxiety and makes me numb.” “It calms the loop of critical thoughts in my mind.” “It helps me forget about the trauma I’ve experienced and makes my life small and manageable.” “It helps me feel worthy and that I have value.” “I’m a perfectionist and it helps me feel I’m doing things right.” “It makes life easier because I don’t have to face the things I’m afraid of.’
Really, by answering the question of “What is this doing for me?”, we can start to understand how this is helping and then start to figure out alternative ways to cope other than the eating disorder. I’ve already touched on many of these in terms of urge surfing or acceptance and commitment therapy or polyvagal theory and self-compassion, but it can also include lots of other things and ideas that can be directly connected to the eating disorder and what to do in specific situations that are connected to that.
But also, a lot of work on bigger picture aspects of life, where someone is creating a life that becomes in opposition to the eating disorder. Life is then pulling you towards recovery.
01:09:49
This final point then connects to the next area of recovery I work on with clients, which is looking at identity and values. In psychology terms, our identity is a collection of beliefs and feelings about how we see ourselves in the world and that make us who we are. Our identity includes how we believe others see us and our social identity, so our perceived membership to or exclusion from different social groups. It encompasses our memories and our experiences and the relationships we have.
For those with an eating disorder, identity can be connected to how they eat and how they exercise and the shape or size of their body. You may think of yourself or are known by your friends as ‘the fit one’ or ‘the healthy one’ or ‘the lean one’ or ‘the thin one’, and these attributes then can become integral to who you are in this world, and keeping up these habits can become immensely important.
To get a sense of identity, you can ask questions like: “I’m the kind of person who… (fill in the blank).” “Growing up, I was always the one who… (fill in the blank).” “People who love me would say I am… (fill in the blank).” “People who don’t like me would say I am… (fill in the blank).” “My work colleagues would say I am… (fill in the blank).”
Then values are things that you believe are important. To quote The Happiness Trap on this, “Values are our heart’s deepest desires: how we want to be, what we want to stand for, and how we want to relate to the world around us. They are leading principles that guide us and motivate us as we move through life.” Values also touch on things like ethics and morality and a person’s sense of right or wrong or what ought to be.
To help discover your values, you can answer questions like: What do I want to be? Who do I want to be? What is important? What really matters in life? Imagine you are in the future 10 years from now and you’re looking back on your life as it is today; complete these three sentences: “I spent too much time worrying about (blank). I did not spend enough time doing things such as (blank). If I could go back in time, the things I would do differently are (blank).”
You can also go through a list of values and pick out the ones that resonate with you. With clients, I use a list compiled by James Clear, which I’ll link to in the show notes, and ask clients to pick their top 5 values.
We can then use this work around identity and values to explore someone’s current life situation. What are the parts of their identity that they like and want to keep? What are the parts that they would like to change? How has the eating disorder impacted on their identity? Based on what they wrote for values, how much is this matching up with their current life? Is what they wrote a reflection of their lived experience, or are the values at this point much more aspirational values? How is the eating disorder currently in alignment with these values? How is it not?
For nearly all clients, they’re able to see that the eating disorder is not supporting their true values, so it’s then about figuring out ways they can change so that this can be different and they can be living more in alignment with their values – and as a knock-on effect, their sense of identity will start to shift.
Now, like many areas I’ve already talked about, this isn’t a quick process, but I really like this values work, as it can be like a North Star and help with choices and decision-making even when these things are challenging. Part of this is because it can help someone to see their true self as separate from the eating disorder self, and that while the eating disorder may be loud and at times feel like who they are, they can notice that actually, it has values and desires that are different to their true nature.
01:13:41
The next area that is important to work on is body image. One of the main features of anorexia and part of the diagnostic criteria in the DSM-5 is an intense fear of gaining weight, but as I went through it, when we look at all the different types of eating disorders, there is a fear of weight gain or body or shape changes or a real focus on self-evaluation based on how the body looks. So really, this area of body image is a hallmark of nearly all eating disorders.
This fear is there irrespective of someone’s actual weight. No matter how low weight goes, this fear never abates. In fact, it often gets stronger. A part of this fear is connected to malnutrition and how the eating disorder affects someone’s thoughts and perceptions. It is incredible how many clients I’ve worked with or am currently working with who talk about how they never had fears or concerns about their weight or their body shape or size before developing the eating disorder. It’s not that these people constantly felt incredible in how their body looked; there could be times of feeling insecure before certain events or at points during puberty. It’s just that on the whole, their body and how it looked wasn’t something they thought about much, and it wasn’t really part of their identity. But once the disease took hold, then the panic about the weight gain ensued. Tabitha Farrar is an example of this, which is something we discussed when she was on the podcast.
But I would also say for many people, maybe most people, body image and weight concerns were a problem before the eating disorder started, and then the eating disorder came along to supposedly help this and actually significantly intensified it.
Body image in simple terms is how we feel about our body. If we broaden this out, we can look at the various components that impact on how we feel. There is visual, like how we see our physical body – and this is never actually as the body is, but is our perception. There is then the emotional, so the meaning and the beliefs we assign to our body. There’s the kinaesthetic, or our perception and connection to the movement and the sensations of our body. Historical, so the lifetime of experiences our body has endured. There’s behavioural, so actions and behaviours that we take based on our body image that then further reinforce our thoughts and feelings and beliefs.
I recently had Summer Innanen on the podcast, and the whole episode was all about body image. One of the most parts of that conversation is how body image is so connected to self-worth, and much of the work of body image isn’t necessarily about how we feel about our appearance, but other aspects of who we are and our sense of worth and our value in the world. Dealing with this comes back to so many of the areas that I’ve already talked about in terms of mindfulness and urge surfing and acceptance and polyvagal theory and healthy coping skills and identity and values and self-compassion.
It can also be looking at things directly connected to appearance in terms of beliefs about thinness and fatness or doing mirror exercises or doing photo exercises, but it’s important to understand that what is often talked about as ‘body image work’ is really the top of the iceberg, and actually we need to look at all the aspects below this.
After the Summer podcast, I also wrote an article all about body image, which I’d also suggest checking out. I’ll link to both the article and the podcast in the show notes.
01:17:17
The next area that is useful to look at and explore is to understand why the eating disorder developed in the first place. For me, this is in service of helping recovery and has a very practical application. It can be very easy for this kind of exploration to turn into something that feels very interesting, but doesn’t lead to actual recovery. In my conversation with Emily Troscianko, we talked about this and how it can be a trip, where it feels like we’re unearthing stuff about childhood or about someone’s personality traits, but actually recovery isn’t taking place.
I’m in agreement with her on this. This can’t be all that recovery is about. Recovery occurs via action-taking. But where I see this kind of exploration as being helpful is how it’s affecting the current situation, and are there specific forms of treatment or changes in the way recovery is approached because of this? Or are there things that the client can now do differently based on this new information?
Let me go through a number of ideas to give you a bit of example of how this could be helpful.
A Highly Sensitive Person. This is something I did a podcast on with Barbara Allen and looked at what this is. If someone is an HSP, this is a permanent trait. This is going to affect their nervous system and how they will experience and tolerate certain situations. So if this is someone’s nature, knowing that this is their nature is really important, and they can then as part of recovery be focusing on creating a life that honours this as part of their nature and helps the HSP aspect to be a strength rather than a weakness.
So often when I’m working with clients, they are unaware of this, so being able to learn this is very helpful in them understanding more about who they are and why things are occurring.
Autism spectrum disorders is another one, and this is something I’m seeing much more with clients. Like with being an HSP, this is permanent. It’s not something that is going to change, and it is so common that clients have developed an eating disorder to deal with the feelings of overwhelm that come with the autism. Or more accurately, they don’t even know that they have autism, and they’re living in a world that isn’t set up for them, that isn’t respecting that as their experience.
So receiving this – and again, I’m not a psychiatrist; I don’t diagnose with anyone, so it’s exploring this and then saying, “Okay, cool, let’s figure out what the path forward with this is to get an official diagnosis if that’s what you want to do, or to understand how this is having an impact.” It can then be looking at what further things need to be done because of this in terms of helping everyday life, in terms of helping the recovery process.
ADD or ADHD. This is similar as I’m talking about with the autism or the HSPs. It’s something that affects how someone processes the world and their internal experience. I had Roberto Olivardia on the podcast recently to talk about this. I’ll link to that one in the show notes as well.
Trauma. Obviously, trauma can mean a huge range of different experiences, and it can have a massive impact. For many clients, their eating disorder developed as a way of coping with the trauma they experienced. I recently did a podcast looking at the many different types of trauma, of healing modalities and how they can be useful. It can be worth seeing if this kind of thing is needed in addition to the eating disorder recovery.
Anxiety disorders. While eating disorders in the long term make anxiety worse, for many clients their anxiety predates the eating disorder. As I talked about with Sasha Gorrell, recovery doesn’t necessarily take away this anxiety, so in a sense, anxiety is a trait, not just a state, and it’s looking at how to deal with that.
Parents’ beliefs about food and body. This could be part of the reason an eating disorder starts, but it also can make recovery more challenging because of the fear of being judged or being ostracized. And I would expand this out and say parents or a parent who is a narcissist or who is a bully or has a negative impact on the child. Maybe this then falls under the bracket of trauma, which I’ve already just mentioned, but seeing as I’m talking about parents here, I thought I would add it. I spoke with Harriet Brown on the podcast all about her experience with a narcissistic mother and her book called Shadow Daughter. I think this is an important thing to recognise.
Food insecurity. This may be something that is still going on, but it may be something that is in the past that is still having an impact. In my conversation with Michelle Viña-Baltsas, she talked about how the pandemic triggered old memories and fears of food insecurity. And this is despite the fact that it had happened decades ago and that she’s done a huge amount of work and now has a very healthy relationship with food. But this experience in the past can be having an impact.
Living in a body that is deemed unacceptable by society. This could be because of race or ethnicity, it could be transgender, it could be because of disability, it could be because of size. Recovery in a lot of ways isn’t going to change these things. Recovery could be taking away the thing that helps someone to feel special or feel like they are passing or feel like they are acceptable.
Loneliness or isolation or boredom. This is something that’s very common with clients in their forties or fifties, with kids leaving home or with entering retirement. For many, this can be the point of life when the eating disorder develops, at this midpoint of life.
Body dysmorphic disorder (BDD). We often think of body dysmorphia as being a symptom of an eating disorder, which it absolutely can be, but kind of like I mentioned with anxiety, for many clients this can predate the eating disorder. The eating disorder has been a way of trying to manage the BDD, but even when they recover, this is still going to be around.
Digestive issues or other health problems. And again, it’s often that these predate the eating disorder and are very likely still going to be around after the recovery process. So the eating disorder had been an attempt to try and deal with this and it is going to be a problem or something that someone’s going to have to deal with after the recovery.
There are lots of other ideas – low self-esteem, going through middle school or high school or college or moving overseas, parents divorcing, a parent going to prison, getting married and the lead-up to the wedding, getting into marathons or triathlons or yoga and this becoming a strong part of someone’s identity and social group, going through puberty and this feeling too early or too late. There are obviously lots of other ideas, but hopefully this gives you a sense of some of them and where we can explore how these traits or how these experiences have shaped someone’s life or their beliefs or their sense of self and how this is connected to current actions and current behaviours they’re making.
Again, from the very practical stance of understanding this so that it can then aid in recovery, so they can get support to better understand their autism, or they can learn to set boundaries with their narcissistic mother, or they can find a provider that offers EMDR to help with their trauma. I think understanding the driver here so that you can know why it is still having or how it is still having an impact can be really important.
So those are all the areas I want to mention as part of recovery. Undoubtedly, I have forgot some things, which is what regularly happens after I post these episodes. I suddenly remember all the other things I should’ve added in.
01:25:31
Everyone’s recovery journey is different. Some of the above are going to be more prominent and salient for some than others. One thing I do firmly believe in is full recovery is possible. As I discussed in my recent conversation with Colleen Reichmann, not everyone’s goal is full recovery. Someone may be after harm reduction, and it’s not for me to tell this person that they are wrong and that full recovery is the only goal they should aim for.
But what I want to do is be an advocate for full recovery in that helping people know that it does exist and that it is possible. I want to have the belief and the hope when the eating disorder impacts on someone’s ability to envisage this for themselves. It’s so common for me to see clients who are trapped in a place of quasi-recovery. In fact, this is often why people reach out to me, because I’ve written so many articles on this and they’ve read so many articles I’ve written on this, and it then really resonates with them. I will link to these articles in the show notes.
Quasi-recovery means partial recovery. In fact, everyone who reaches full recovery will go through this stage. Quasi-recovery is when things aren’t as bad as they were when they were at their worst. You’re now feeling less cold, you’re now able to eat foods that you couldn’t eat before, you’re now not following a rigid exercise routine, and this then frees up more time for you to do things that help you feel more satisfied. You have an increased ability to concentrate and find that you’re less irritable.
What turns quasi-recovery into a problem is when the process of recovery ceases to move forward. So rather than quasi-recovery being the place that you travel through as you go to a place of full recovery, it now becomes the destination and the place someone stops at.
There can be many reasons for this occurring. It can be a misunderstanding about how much recovery has occurred and yet how much more there is to go. For example, this extreme hunger has stopped, or the binges or purging has stopped, or periods have come back again, or exercise has been ceased for some amount of time, or blood markers have improved. There is some marker or markers that are being used to determine that recovery is over, when in fact there is still more to occur.
Or the very common one: that some weight has been reached, that a goal weight that was set has now been achieved, or someone simply believes that they are at a weight that is enough, and that this indicates that recovery must be over. I actually wrote a whole article on this and how it not only impacts an individual’s belief, but also how it impacts research outcomes and how recovery is defined.
Why this is such a problem is that while things have improved, they haven’t improved entirely, and yet someone could get the impression that ‘this is as good as it gets’. And if they are noticing that life isn’t really that much better, it’s easy to go back towards disordered behaviour.
Why I want to take such a broad view with recovery and look at all the ways it has infiltrated into someone’s life is because someone may have reached a place of nutritional rehabilitation, but if there’s still a lack of coping skills or an inability to set boundaries, or there’s a lack of self-worth or self-compassion, these are areas that need to be worked on, because if they aren’t, there is a high likelihood that relapse will happen.
The greatest risk of relapse is up to 18 months after recovery, but it can still happen much later than this. I’ve had many clients who have recovered from an eating disorder in their teens or early twenties, only to then relapse in their thirties or forties. A big part of this is because there were skills that weren’t learnt in the recovery process the first time around.
For me, full recovery isn’t simply about being able to accept your body size and shape and no longer having a destructive or damaging relationship with food and exercise; it’s about building the skills and the resilience in all areas of life, which is so much of what I’ve covered today. I’ve never had an eating disorder, but so much of what I’ve covered, whether it’s about mindfulness or self-compassion or noticing sensations and emotions or values, etc., is critical to my wellbeing and healthy functioning. This is going to be an ongoing and a lifelong practice.
I do use the term ‘full recovery’ rather than ‘in recovery’, like is common with AA and recovery from other drugs, but I still think of this being a lifelong practice. Or at least much longer than the idea of just putting in work for six months or a year and then being recovered. This is a long-term project with the time of the start obviously being much more acute, but where you can learn things in Year 3 or Year 4 that are every bit as valuable.
Recovery is challenging, and it isn’t a quick fix. I really do believe that getting support is an important step as part of this process. While there are those who have truly recovered on their own, I think of them as the exception and not the rule. It can feel scary or embarrassing to seek help for an eating disorder, which is why I think it is crucial to get help that is supportive and is non-judgmental. You don’t have to pretend that you are fine when you really aren’t. You also don’t have to pretend or hide what’s going on for fear that you’re going to be lectured.
Despite the eating disorder thoughts, there is a healthy part of you, and one that sees all the problems this is causing and how much life has fallen by the wayside, and that you would like life to look differently.
Ambivalence is at the heart of all change. This is especially the case with recovery. It’s totally normal to fear recovery and to long for it at the same time. I’ve worked with clients for over a decade now, helping them to recover from many different types of eating disorders. So if you want to recover, even if you feel ambivalent, I would love to have a chat with you.
As I mentioned at the top, I’m currently taking on new clients. If you want to head over to www.seven-health.com/help, you can read more about how I work with clients. I offer a free initial chat where you can talk about what’s going on and where you’d like to get to, and you can find out more about what working together would look like. I want you to get to a better place with recovery, whether that is full recovery or harm reduction, and I would love to be able to support you through that process.
That is it for this week’s episode. I hope that you found it helpful. If you have, and there are others who you know of or you have in your life who you think would benefit from it, please share it. It has taken a lot of time and effort to put this together, and I want as many people to hear it and benefit from it as possible.
I’m away next week; I’m on holiday in the New Forest. There will be a rebroadcast episode coming out then. But I will be back with a new episode shortly. Until then, take care, and I will catch you soon.
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Brilliant show. Sums up almost everything about ED and how to recover from it.