Eating disorders: Our Efforts to Diet and Why It’s Never Worked
- Aaradhana Reddy
- Dec 30, 2022
- 22 min read
Eating Disorders are maladaptive eating behaviors, emerging from body image dissatisfaction and strong perceived negative beliefs about their body size; which results in significant functional deficits in work, personal and social life and can also result in death. Eating disorders are being increasingly seen in both the adolescent and adult populations. Harmful dieting, excessive exercise, cycles of binge eating and purging, cutting extremely on food intake, are all increasing in incidence. And we do this to fit into an impossible, filtered ideal image that is constantly being shown to us by both conventional and social media. It is also an ideal Eurocentric standard of beauty that has become ‘the’ standard in other parts of the world as well.
Contents
Eating disorders: Types and DSM V Guidelines
The most common that are observed are Anorexia Nervosa and Bulimia Nervosa.
Anorexia Nervosa:
A. Restriction of food intake is observed leading to significantly low body weight (weight less than the minimum normal or expected weight) with regard to their age, sex, developmental trajectory and physical health.
B. Intense fear of gaining weight or of becoming fat and persistent behavior that comes in the way of gaining weight even though the individual show significant low body weight.
C. Disturbance in the way one’s body weight or shape is experienced. A significant chuck of their self-evaluation is based on their body weight and shape. They don’t recognize the seriousness of their significant weight loss.
Mild- BMI more than 17
Moderate- BMI 16- 16.99
Severe- BMI 15-15.99
Extreme- BMI less than 15
Note: During the last three months, the individual has not engaged in binge eating and purging cycles; and their significant weight loss is primarily due to restrictive food intake.
Partial Remission: After meeting a full criterion of Anorexia, currently criteria A is not met for a sustained period of time, but Criteria B and C are still met.
Full Remission: After meeting a full criterion of Anorexia, current none of the criterions are met for a sustained period of time.
Bulimia Nervosa
A. Recurrent binge eating characterized by the following:
Eating within a period of time any two-hour period; an amount of food that is larger than most people who would eat in a similar period of time under similar circumstances.
Experiencing lack of control with food intake and what and how they are eating.
B. Recurrent maladaptive compensatory behaviors after the binge eating episode to prevent weight; such as, excessive exercise, laxatives, self-induced vomiting, diuretics, fasting etc.
C. This binge eating and purging cycles have occurred at least once a week for three months.
D. Self-evaluation is unduly influenced by body weight and shape
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Mild- 1-3 inappropriate compensatory episodes per week
Moderate: 4-7 inappropriate compensatory episodes per week
Severe: 8-13 inappropriate compensatory episodes per week
Extreme: 14 or more inappropriate compensatory episodes per week.
Partial Remission: After meeting a full criterion of Bulimia, currently some but not all are met for a sustained period of time.
Full Remission: After meeting a full criterion of Bulimia, currently none of the criterions are met for a sustained period of time.
Binge Eating Disorder
A. Recurrent binge eating characterized by the following:
Eating within a period of time any two-hour period; an amount of food that is larger than most people who would eat in a similar period of time under similar circumstances.
Experiencing lack of control with food intake and what and how they are eating
B. Binge Eating episodes are characterized by three or more of the following:
Eating faster than normal
Eating until feeling uncomfortably full
Eating large amounts of food when not physically hungry
Eating alone due to embarrassment by the amount of food one is eating
Feelings of disgust and guilt after binge eating. Some can also be depressed afterwards.
C. Marked distress regarding binge eating is present.
D. Binge eating episodes occur once a week for three months on an average.
E. This is not associated with inappropriate compensatory behaviors afterwards like in bulimia. And these episodes have not occurred exclusively during the course of bulimia or anorexia nervosa.
Mild: 1-3 binge eating episodes per week
Moderate: 4-7 binge eating episodes per week
Severe: 8-13 binge eating episodes per week
Extreme: 14 or more binge eating episodes per week
Partial Remission: After a full criterion of binge eating has been met, current less than one episode per week for a sustained period of time is observed.
Full Remission: After a full criterion of binge eating has been met, currently none of the criteria is met for a sustained period of time.
Other eating disorders mentioned in the DMS V are Avoidant /Restrictive Food intake disorder; where an individual shows marked disinterest in food, avoids eating based on looks of food, resulting in weight loss, nutritional deficiencies, need of oral food supplements and marked psychosocial deficits.
Indian and Global Scenario: Prevalence
Eating disorders, such as bulimia nervosa, anorexia nervosa, binge eating disorder, ARFID (avoidant restrictive food intake disorder) etc., have become increasing common among the general population and especially among adolescents. The age of onset for any eating disorder is 21 years and for anorexia and bulimia its 18, with women having higher rates of eating disorders than men.
In India, study among 1600 adolescents, as high as 26.06% of adolescents were prone to any eating disorders. Eating disorders are commonly associated with comorbidities of depression and low self-esteem. Anorexia, Bulimia, binge eating disorder and other specified eating disorders accounted for 6.6 million DALYs (disability adjusted life years). The burden was higher among females, than males and the disease burden peaked between 25-29 years in females and 30-34 years in males (Damian F Santomauro, 2021). The age of onset has decreased with anorexia being reported at younger age (less than 15 years), although we don’t know if its because of earlier age of onset of increased early detection. Life time prevalence of anorexia is 4% among females and 0.3%among males, for bulimia its 3% and 1% respectively. 5% increased risk of mortality is observed in cases of both anorexia and bulimia. The incidence in females for anorexia was 25.7 per 100,000 and in males it was 2.3 per 100,00. (Eeden, Hoeken, & Hoek, 2021).
There are hardly any studies and nation-wide statistics on the prevalence of eating disorders in India. By the 20th century disordered eating patterns started to rise in non-western countries as well, especially in high income non-western countries. In India, disordered eating patterns which could be subthreshold eating disorders could have ranged from 4% to 45.4%. Reports of eating disorders in India, were only starting to be reported in the mid 1990s. They were first reported among Hindu women aged 15-22. The symptoms they exhibited were vomiting, amenorrhea, significant weight loss, refusing to eat, physical complaints etc. In one study, it was found that Indian participants binge ate more than Australian participants, but the laxative, vomiting and food restriction periods were similar. Studies done on the etiology (causes) showed that socio-economic factors such as body shape, societal standards, family stressors, failure to reach parental expectations etc. Coming to the effects of eating disorders, a study in 1995 showed that mortality rate was 5.9%. 27% committed suicide, 54% died of eating disorder complications and 19% died of unknown causes (Motwani, Karia, Mandalia, & Desousa, 2021).
Risk Factors of Eating Disorders
I will categorize risk factors according to the biopsychosocial model, which will give us a holistic picture.
Biological Risk Factors:
Genetic factors and researches on this aspect mostly focus on the genes related to dopamine, serotonin and BNDF (Brain Derived Neurotrophic Factors). Dopamine related genes show no association with Anorexia or Bulimia, but show a relationship with Binge eating disorder. “Dopaminergic neural pathways have shown associations with non-homeostatic feeding behavior, reward-based learning, and food reinforcement suggestive of enhanced dopamine neurotransmission and hypersensitivity to reward” (Bakalar, Shank, Vannucci, Radin, & Tanofsky-Kraff, 2015, p. 2). The s-allele has shown an association with Anorexia and adolescent girls who have experienced adverse life events in their life and who also carried the s-allele gene showed an association with Bulimia; thus, they are at risk of eating disorders. With regards to structural changes in brain and its association with eating disorders; reduced gray matter in areas that are associated with reward, appetite, mental representation of body etc. are associated with AN. Individuals with AN also showed increased fear activation when exposed to food cues.
Researches have also suggested some perinatal risk factors for future development of eating disorders. In utero exposure to chickenpox or rubella is a risk factor for AN, low maternal Vitamin D levels at gestation, maternal obesity, higher paternal age are all risk factors for future development of eating disorders. For individuals with an opposite sex twin (exposure to testosterone at prenatal stage) showed decreased risk of disordered eating at mid and late adolescence as opposed to individuals with same sex twin. Testosterone has shown to act as a protective factor against disordered eating. It is said that the presence of testosterone at the perinatal stage decreases the effects of ovarian hormones; in turn decreasing the risk of eating disorders in mid to late adolescence. Ovarian hormones which largely influence female puberty are said to make changes in the gene transcription that regulate eating (serotonin systems), thus influencing genetic risk. This is why genetic risk for females before puberty is 0% and after puberty is 51%. Since, protective testosterone is present in boys at an early age the genetic risk percentage of 51% remains stable across life stages for boys (Bakalar, Shank, Vannucci, Radin, & Tanofsky-Kraff, 2015). Childhood obesity, significant weight loss or weight gain, as opposed to stable weight across life years are all known to be risk factors for development of eating disorders like Bulimia, Binge eating disorder etc. (Bakalar, Shank, Vannucci, Radin, & Tanofsky-Kraff, 2015). Individuals with BN showed less response to taste and reward pathways; especially when eating sweet foods. Individuals with Binge eating disorder and bulimia also showed impairments in self-control. Alterations in neural regions associated with self-referential processing, somatosensory processing, perception of body stimuli, and processing may underlie body image distortions observed among individuals with AN and BN (Bakalar, Shank, Vannucci, Radin, & Tanofsky-Kraff, 2015, p. 4).
Psychological Risk Factors
Personality traits such as perfectionism, interpersonal distrust and higher maturity fears predicted the onset of eating disorders; while perfectionism was the only factor to maintain eating disorders (Bakalar, Shank, Vannucci, Radin, & Tanofsky-Kraff, 2015). Traits such as harm avoidance (inhibiting responses in cases of adverse stimuli, leading to avoidance of punishment, non-reward [ (Matton, Goossens, Vervaet, & Braet, 2015, p. 230)] less sensitivity to rewards, low novelty seeking (novelty seeking is responding actively to new stimuli, leading to reward and escape from punishment [ (Matton, Goossens, Vervaet, & Braet, 2015, p. 230)] all predicted Anorexia; while the opposite predicted Bulimia. Increased harm avoidance has also been seen in Binge eating disorder. Sensitivity to reward (SR) is also associated with Binge eating and increased SR is associated with Anorexia binge eating and purging type and Bulimia Nervosa. Another perspective posits that rash impulsivity/novelty seeking and not SR is related to binge eating because of presence of impulsivity in binge and purging behaviors. SR then is known to be partly associated with sensitivity to social rewards and physical rewards from disordered eating behaviors that can be applied to all eating disorders. Another perspective says that both novelty seeking/rash impulsivity, sensitivity to rewards are associated with binge eating; where he former is associated with loss of control experienced during binge eating and latter is associated with binge cravings (Matton, Goossens, Vervaet, & Braet, 2015). Another trait of negative urgency (reacting harshly during distress) is known to be a predictor of binge eating behavior (Bakalar, Shank, Vannucci, Radin, & Tanofsky-Kraff, 2015).
Externalizing Behavior problems (problems with attention, thoughts, rule breaking, deliquesces, aggressive behaviors) and internalizing behaviors (social problems, anxiety, depression, withdrawn and somatic complaints) predicted eating disorder persistence. Externalizing behaviors were preceded with Bulimia onset and internalizing behaviors in childhood predicted anorexia onset. Eating, body shape attitudes and weight overconcern are all linked to partial or full eating disorder onsets. Loss of control in eating is associated with 4-5-fold increased risk of binge eating. Young adult risky dieting significantly predicted binge eating disorder; while dieting and subsequent binge emerged in males later than in females. “Eating disturbances were more likely to begin with dieting behavior in anorexia and binge eating most often marked the onset of eating disturbances in bulimia and binge eating disorder” (Bakalar, Shank, Vannucci, Radin, & Tanofsky-Kraff, 2015, p. 5). ADHD, anxiety, conduct and substance use disorders co-occur with eating disorders. Childhood OCD and depression are known to increase the risk of future eating disorders; especially anorexia by 6 fold. Individuals with bulimia are 8 tie more likely to have had childhood ADHD and 5 times more likely to have co-occurring ADHD. Early detection and intervention in critical periods in development such as adolescence can help greatly in prognosis.
Sociocultural Risk Factors
Interpersonal distrust, lack of social support, perceived pressure to be thin, internalization of thin ideal are risk factors that maintain and play a role in onset for eating disorders, especially in adolescents which also extends to young adulthood (Bakalar, Shank, Vannucci, Radin, & Tanofsky-Kraff, 2015). Media is also seen to a significant factor in the internalization of thin ideal and other sociocultural ideal standards related to appearance. Internalization of these norms were associated with bulimia tendencies in young girls (12-15) (Izydorczyk & Sitnik-Warchulska, 2018). Teasing in general and also body related teasing is shown to elevate the risk of anorexia, bulimia and binge eating disorder. Negative comments from close family, friends, teachers, coaches about weight, eating, body shape etc. also predicted onset of eating disorders. Adverse life events, especially of an interpersonal nature such as abuse, assault, emotional abuse etc. is prevalent among both men and women with eating disorders. The emotional consequences of maltreatment such as mood instabilities and disorders can contribute to disordered eating. Body dissatisfaction in early adolescence was the consistent predictor of eating disorders later in life at 13 years. Thin ideal internalization, negative affect, perceived pressure to be thin, dieting also predicted future eating disorder risk (Rohde, Stice, & Martie, 2014).
Self-esteem and Eating Disorders
Many researches have consistently found a link between self-esteem, pathological eating and future risk of eating disorders. Low self-esteem is a risk factor for disordered eating and it can lead to increased disordered eating over time. Many models suggest self-esteem as critical developing, preventing and treating eating disorders. Self-esteem has been found to be a risk factor, irrespective of eating disorder type, body mass index, sampling method, age etc. (Colmsee, Hank, & Bošnjak, 2021). In a study done among obese college women; those who reported binge eating, also reported low self-esteem and appearance dissatisfaction (Herbozo, Schaefer, & Thompson, 2015).
Social Media and Eating Disorders
A robust connection has been found between social media usage and body dissatisfaction, appearance comparison, drive for thinness, ideal image internalization, disordered eating etc. With regards to covid impact, there was significant increase in the usage of social media. Social media sites like Instagram and YouTube have taken the lead. Following appearance focused accounts increased significantly during covid and this was linked with higher drive for thinness. This might increase the risk of eating disorders. Among Gen Z participants Instagram usage was linked to body image dissatisfaction, drive for thinness and low self-esteem. Among the Gen Y it was only linked with drive for thinness (Vall-Roqu´e, Ana, & Saldana˜, 2021).
Body image is comprised of an individual’s perception of various aspects of their body. These perceptions consist of cognitive aspects that in turn direct their emotions and behavior. These perceptions and cognitions are formed and influenced by things significant others (parents, relatives, peers) say and also by conventional forms of media and social media. The ideal body images that are posted and seen on various forms of media, are them consumed and internalized by individuals, who then strive to achieve them by methods which can be very harmful both physically and mentally. Recently there are two ideal body images that exist; the athletic ideal and the thin ideal. Athletic ideal predicts compulsive exercise and thin ideal predicts disordered eating, which is a risk factor for eating disorders. Self-esteem, degree of body dissatisfaction were also related to disordered eating outcomes (Aparicio-Martinez, et al., 2019). As we have seen in our article about body dysmorphic disorder, upward self-comparison of social media posts by others; which are edited and idealized leads to body image dissatisfaction, low self-esteem; which then leads to body change. Read more about social media and Body Dysmorphic Disorder.
Problematic social media use which includes compulsivity, mood alternation, negative outcomes etc. is related to decreased body image, lower self-esteem, higher eating disorder symptoms, depression etc. Specific social media grooming behaviors like lurking (visiting and scrolling through other people’s profiles, liking and commenting on their posts without any actual conversation with them) is linked to lower body image. Although there is a greater chance of connecting with peers; there is also a chance for comparison, which then leads to involving in risk eating behaviors, dieting etc. to achieve the ideal body as the posts. Active use is shown to be healthier than passive use. Individuals engaging in maladaptive facebook usage (those with upward social comparison and eliciting negative social evaluations on facebook) exhibited bulimic symptoms, body dissatisfaction and shape concerns. Appearance focused posts that initiate related conversations can also exacerbate existing body image concerns, upward comparisons, etc. Viewing appearance related posts also increased weight dissatisfaction, drive for thinness and internalization of thin ideal. While as posting pictures of oneself was related to basing self-esteem on appearance and internalizing thinness as ideal (Holland & Tiggemann, 2016). Some longitudinal researches also suggest that social media can play a role in predicting and in the development of body dissatisfaction and disordered eating upto 18 months. Researches have suggested that more friends mean more exposure to more idealized images and high social comparison which all increase body image dissatisfaction, higher dieting behaviors, drive for thinness and internalization of body ideals (Holland & Tiggemann, 2016). Hence, appearance comparisons mediate social grooming behaviors and drive for thinness. Gender differences were not found in this aspect, but other researches suggest that, males go in for muscularity and females pursue thinness. There may be cultural differences as well, but more researches should be conducted in this area to understand the processes in depth (Santarossa & Woodruff, 2017; Kim & Chock, 2015).
Why dieting doesn’t work?: An Evolutionary explanation
The environmental contribution to eating disorders; our society’s obsession with thinness, the ideal or rather impossible body image, various forms of media available to children and adolescents. Girls as young as 6 are concerned about becoming fat, girls and boys are bullied because of their weight. And during puberty, while boys become muscular, girls ten to gain fat, preparing the body for reproduction; hence, moving away from the ideal body image. All of which drives them towards dieting; as we have seen earlier is a risk factor for eating disorders.
Yes, dieting will lead to weight loss in the short term, but it almost always leads to gaining back those lost kgs in the coming years. No diet as ever shown to work in the long run. People tend to gain back the weight they’ve lost in 1-5 years. Dieting is a short-term plan and if one is to follow through restrictive dieting, one has to stay in the same unsatisfying diet for the rest of their lives. A word of caution, please do not follow any advertisements for short and quick way their ‘magic’ pill/powder/plan to lose weight. They do not work and maybe unhealthy. Any overly unsatisfying restrictive diets can be harmful to health and can lead to binge eating and purging cycles. Read more on dieting.
This weight cycling, due to short-term diets and eventual regaining of weight; popularly known as yo-yo diets; are also harmful for health; as much as obesity is if not more. Weight cycling is associated with visceral fat accumulation, which increases the risk of cardiometabolic risks; which are high fasting insulin levels, increased risk of heart attack, cholesterol levels and stroke. It is also associated with higher triglyceride levels, which is a risk factor for coronary heart disease. Females had worse lipid profiles and insulin resistance. Males had higher HDL. Weight cyclers with normal weight has worse HDL and LDL profiles (Kakinami, Knäuper, & Brunet, 2020; Strohacker, Carpenter, & McFarlin, 2009). Although sustained obesity is a higher risk than weight cycling, people with normal and natural weight; who are yo-yo dieting are under risk of the above-mentioned factors.
There is an evolutionary explanation for why dieting doesn’t work and why it becomes more difficult to shed the regained weight a second time. The Pleistocene epoch, has seen the ice age, extreme climate shifts; hence, there were periods of abundance during a kill and periods of starvation. We adapted to this by storing enough fat, to use during times of starvation. Here comes in natural weight, it is the set point of weight, body needs to survive and function optimally, and the body defends this weight vigorously. So, during restrictive dieting body maintains its weight through stored fat’s energy, reducing metabolism etc. So, when we are trying to diet, the body notices rapid weight reduction (our body doesn't understand self-imposed starvation, during time of abundance), and defends the natural weight through refusing to shed fat, lowering metabolism and demanding food; which is where we get craving for food from when dieting. However strong our will, the body’s defenses are stronger; then leading to binge eating; resulting in shame or terror about weight gain and purging; causing bulimia or it could lead to a binge eating disorder. Almost everybody is on diets before the onset of bulimia (Seligman, 2007). Seligman In his book What You Can Change and What You Can’t, proposes that Bulimia is caused due to dieting. During the restrictive dieting we usually see, the body tries to defend its natural weight; and the more she restricts the better the body gets at storing fat. At breaking point, the body defenses take over and the individual binge eats. After which the individual feels guilt and scared of gaining fat (body image), the individual resorts to purging. Seligman also posits that; the societal ideal weight and natural weight have a lot of discrepancy. Individuals whose ideal weight and natural weights are massively different; are at a higher risk of eating disorders. I recommend you all to watch this TED talk by Sandra Aamodt on why dieting doesn't work.
So, how do we manage this. Our benchmark has to change. Our goal is not thinness, not reducing fatness; its fitness; our goal is not ideal body image; but natural weight. The second factor is eating when hungry; also called as mindful or intuitive eating. We eat when we are hungry and stop when we are full. we concentrate on what we are eating, savor it and be in touch with our signals that say we are full. Ask yourself am I eating this because I am hungry or because its tasty. This is only possible when we eat without distractions. Even when feeding kids, it is important for us to stop when the kid says I am full; by ignoring this we are teaching them to ignore such signals as well.
Coming to natural weight, unfortunately, there is no concrete number or way to identify natural weight. BMI scores have nothing to do with natural weight. But there might be some factors that indicate you are at your natural weight. Although, factors of illness must be taken into account. If you are able to eat foods you enjoy, move your body, not binge eat, getting sound sleep, eating when hungry, good appetite, good metabolism, you are probably at your natural weight. This weight might not necessarily mean the slimmest or ideal shape. And after this point dieting may not work and we would have to push ourselves to go to extremes like skipping meals to get slimmer. Hence, our action, is not dieting, but a balanced diet and exercise. and eating when hungry.
Treatment
The line of treatment for eating disorders includes psychotherapies, pharmacological treatments and other disciplinaries; like dietitian, nurse, psychiatrist, nutritional specialist, pediatrician, when necessary, exercise therapist, occupational therapist etc.
While as more severe cases of especially anorexia, bulimia and binge eating disorder require hospitalization and above-mentioned team. Mild and moderate cases, outpatient services of a psychotherapist, family doctor and nutritional specialist will suffice (Hay, 2020).
Psychological Approaches
Enhanced Cognitive Behavior Therapy: CBT-E, while maintaining the basic conceptualization of Cognitive Behavior Therapy; CBT-E also looks at the transdiagnostic maintaining factors. Meaning, CBT-E looks at certain common factors that maintain or act as perpetuating factors among various eating disorders. CBT maintains that, especially for bulimia, is that the start of it is their maladaptive way of evaluating their self-esteem. Starting from middle childhood and adolescents, we start evaluating our self-worth on our performances in various aspects of our life. Individuals with eating disorders evaluate themselves exclusively on the appearance related aspects such as weight, shape, eating habits and their ability to control these aspects. Hence, they become highly focused on their shape, becoming thin, dieting and other weight loss methods. As CBT is all about dysfunctional thoughts leading to our disturbances; the core factor that maintains bulimia is the dysfunctional over-evaluation of eating habits, shape and weight. Hence, the strict dieting and other weight control behaviors are the direct consequence of the dysfunctional thought and the binge eating is the result of this overly restrictive diet control (Fairburn & Zafra Cooper, 2003).
The enhanced cognitive behavior therapy takes other core aspects into account such as their interpersonal aspects. CBT-E proposes four additional factors that maintain eating disorders.
Clinical Perfectionism: Clinical perfectionism is defined as the over-evaluation of striving for the achievement of highly demanding personal standards, despite their negative consequences. And at the core of this is the judgement of one’s self-esteem on them meeting these standards. And perfectionism as suggested by researches is associated with eating disorders. Their standards to achieve the perfect body shape and weight and their subsequent attempts to control them and sometimes also other aspects of life like work. And also, their fear of failure of meeting these standards (frequent self-checking of their weight, fear of weight gain, over eating etc.). The negative appraisal of their efforts, can lead to even more determination to dieting and weight loss behaviors. All these thereby, maintaining the eating disorder.
Core low self-esteem: While some have negative sense of self, because of their inability to meet their appearance related standards; some others have a global universal negative sense of themselves. It doesn’t chance with their performance and such core low self-esteem tends to obstruct chance because of their hopelessness about their ability to change. Any domain where they feel they make changes and are in control, they tend to hold on to them with high determination. If they are doing this with eating habits, weight and shape; change is difficult to come by. And any perceived negative outcome or failure is seen as a confirmation of their negative view of themselves. Cognitive biases such as over generalization are present.
Mood intolerance: Mood intolerance is the inability to cope with emotional states. It is also known that; individuals may cope with adverse moods can lead to binge eating. Individuals engage in dysfunctional mood modulating behavior, instead of coping with them appropriately (anger, anxiety, depression etc.). For individuals with bulimia, the binge eating and purging cycle can become their way of regulating their moods.
Interpersonal difficulties: Interpersonal difficulties can often exacerbate disordered eating habits and hence maintain the disorder. It is often observed that in early onset cases, interpersonal difficulties can increase their resistance to eating; as a way to get a sense of control, which is shown on eating. It is also seen that; adverse interpersonal events act as catalysts to binge eating episodes. Chronic interpersonal difficulties result in low self-esteem, which as observed earlier can lead to determined efforts to weight loss activities including disordered eating, to maintain shape and weight. Hence, individuals with interpersonal problems can have bad prognosis as well (Fairburn & Zafra Cooper, 2003).
Transdiagnostic Perspective: Core schemas of Anorexia and Bulimia are very similar; where over evaluation of eating habits, weight and shape, body checking, fear of gaining fat etc. But the way this psychopathology is expressed is different. In Bulimia there is no significant body weight reduction because the binge eating and purging cancel each other out. But in Anorexia, significant low body weight is very visible and symptoms of starvation are seen. Although, there is variation of binge and purging cycle occurring in Anorexia as well. There is also evidence that, individuals who unsuccessful treated for anorexia, may develop Bulimia. Hence, the above-mentioned factors can be seen as maintaining factors across eating disorders (Fairburn & Zafra Cooper, 2003).
Fig 1. Showing the factors that maintain eating disorders; according to the CBT-E model. 'Life' in the picture represents interpersonal life. (Fairburn & Zafra Cooper, 2003).
Family Based Therapy: Family based therapy is a new line of treatment, that has been increasingly used to deal with eating disorders. This line of treatment helps in empowering the parents to bring changes in their child. Therapists trained in this therapy do not exclusively focus on causes, but focus on trying to make immediate family a support system and a resource to bring out behavioral change. It is important to take the blame away from parents, focus on causes and help them move towards empowerment to help out their child. A non-authoritarian stance and collaborative approach is emphasized in FBT. Hence, parents are seen as experts on their child and the therapist is an expert consultant of the therapy. The parents are told what to do, but are not told how to do it. Parents might feel defeated by eating disorders and might have given up dealing with it, feeling discouraged. The therapist must then help the parents realize that, they know how to give nutrition to the child, like they did before their child developed eating disorder.
One of the main tenets of this therapy is the externalization of illness. Meaning, to help the parents realize and put into practice the separation of the adolescent and illness. Parents might go through a variety of emotions when they see their child restricting their food, becoming sick and malnourished; such as fear, anger, frustration etc. But, showing them on the child might not help. So, it helps to separate the two and realize that, the parents are fighting a powerful disorder, that their child is under the influence of and not their child.
FBT unlike CBT-E, is focused on symptom management with a heavy behavioral component. It maintains that, eating disorders have high mortality rates so, focus on behavior first and helping them out of the danger first is crucial and then emotional changes may follow (D.Rienecke & Grange, 2022).
Pharmacological Therapies
There hasn’t been much advances in terms of medications for eating disorders. Anti-depressants are used with no direct role in treating anorexia or bulimia; but when there is comorbid major depressive disorder. For binge eating disorder and bulimia, there are several trials for the use of higher dose selective serotonin reuptake inhibitors. There are also meta-analyses that support the use of second-generation antidepressants and lisdexamfetamine. But these are to be used in conjunction with psychotherapies and not as stand-alone treatments (Hay, 2020).
Note: If you or anyone you know are suffering from any of the eating disorders or are at risk of developing one, please seek help and encourage others to seek help. Eating disorders have high mortality rates if untreated. Visit our services and booking page for help.
References
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