What is an eating disorder? – The importance of nourishment controlling behaviours in the service of self-worth

In her scholarly Viewpoint, Hay (2013) states the need to establish a core psychopathology for the definition of an eating disorder and its distinction from other diagnostic groups. This is proposed to include ‘body image, shape and weight and eating concerns that drive and are driven by disordered eating and weight or body shape control behaviours’ (Hay, 2013, p. 210). Much has already been written about the absence of these concerns in certain patients with eating disorders (Hsu and Lee, 1993) which would include some of our own. Cultural influences notwithstanding (Watters, 2010), the view expressed would still seem unduly simplistic and not supported by clinical experience or enquiry.

Patients of the author were adamant that body image and allied concerns were secondary factors in their eating disorders and issues around self worth, control, mood management, sense of purpose, change, loss, grief and dissatisfaction emerged most strongly with self worth and control way out ahead of the rest. What these young women all had in common was what they had chosen to do about these issues; namely change their way of managing their energy balance by eating less, purging and/or exercising excessively until they felt better about themselves, initially at least. The bodies of some had become increasingly emaciated to the point of medical compromise but others had fought back vigorously with binge eating and weight gain. The owners of these bodies had then retaliated with renewed weight losing behaviours and ultimately a conspicuous lack of success, along with a deteriorating emotional state and a variety of weights from the anorexic threshold to the upper part of the normal range and beyond. Their psychopathology was also quite variable.

So eating disorders might be best seen as pathological, psychologically driven conditions in which not only eating but drinking and exercise behaviours, which together determine nourishment status, are abnormal in terms of energy balance (Abraham et al., 2007; Hart et al., 2010). Intake can range from deficient or relatively deficient and unbalanced to temporarily normal or excessive; i.e., binge eating and drinking in response to self starvation and fluid restriction, hunger, activity levels, metabolic needs, genetic predisposition and emotional regulation. Disordered nourishment behaviours can be continued or intermittent over differing time intervals. Increased engagement in weight losing behaviours tends to follow increased intake or binge eating, particularly when this is experienced as out of control and the behaviours are then termed ‘compensatory’. The latter term could refer equally well to compensating for a poor sense of self worth through not being what one wants to be or covets in others.

The body is meanwhile trying to compensate for starvation as we are all physiologically addicted to food and fluid and need to be in order to survive. If we fail to eat and drink enough, for long enough, the need for nourishment may emerge in the form of perverse addictions to behaviours related to eating or not eating such as binge eating, or those substituting for eating. These include starving, purging, exercising, drinking, drugging, cooking, collecting cookbooks, shopping or even shoplifting. However eating disorders are, in themselves, not true addictive disorders.

Nourishment disorders are based on the very human need to exert control over both energy and fluid supplies for the body and the supply of emotional nurturance through the sense of self worth. In our affluent society, certain individuals may be prepared to sacrifice food, fluid and physical comfort, all of which are in such assured supply, for self worth and emotional nurturance which may be experienced as scarce or conditional. Their underfed or otherwise challenged bodies might initially bring admiration and a spurious sense of control, followed by concern, care and nutritional rehabilitation which will often be resisted until medical complications supervene and family, carers, friends, workmates or even regulatory bodies step in.

The developmental perspective is important with adolescence or impending adolescence bringing challenges around control, pubertal body changes, identity, separation/individuation and loss. These things are reworked later in the life cycle with pregnancy, parenting, menopause/andropause then the need to face one’s own bodily dissolution with ageing, other losses and finally one’s own demise. Yet the paradox of eating disorders is that the sufferer is denying yet involving herself or himself in death dealing but death defying behaviours (Russell and Meares, 1997) beginning most often at an early age.

Hilde Bruch, a pioneer in understanding eating disorders, coined the term ‘me-too anorexics’ (Bruch, 1985, p. 11). These individuals tend to be at the forefront in agitating for treatment services and account for much of the arguable ‘epidemic’ of eating disorders other than anorexia nervosa. As my patients confirmed, ‘real anorexics’ are usually too secretive and ambivalent about treatment to engage in such advocacy.

The incidence of anorexia nervosa in the Western world (Hoek and van Hoeken, 2003) seems to have ‘ceilinged’ in the seventies with globalization and deregulation of markets (Reich, 2008). Advertising, particularly aimed at the self-esteem and image concerns of youth, has burgeoned from that time on in order to sell the glut of cheaper products. Social networking has continued this trend. Most of those who were genetically predisposed to develop anorexia nervosa probably did so at that point and are most likely continuing to do so now. The difference in recent decades is that many more seem to be trying and keeping on trying. The odds may be stacked against them succeeding in their ‘relentless pursuit of thinness’ (Bruch, 1985, p. 9), but they do succeed, however, in developing and often maintaining an eating disorder with a different diagnostic label. This may be in concert with other psychiatric diagnoses or personality derailment which can be cause or effect and which may bring the sufferer into treatment before the eating disorder does.

Even here, where the psychopathology is still more variable, it is again the behaviour around control of nourishment of the body in the service of self worth and emotional nurturance that is at the core or more properly, the very heart, of an eating disorder.