Treating Eating Disorders: The Second Assumption

In a previous article I suggested we consider a few basic assumptions that seem to apply when speaking about eating disorders. Before moving on, I’d recommend looking at what all the various forms of eating disorders have in common rather than addressing them in terms of their differences. By this time most of us are familiar with the “clinical criteria” of anorexia, bulimia, and binge eating disorder. Unfortunately, the medical criteria delineating between each of these has led many to “not see the forest from the trees.”

Ok, let’s take a moment and “think outside the box” and ask what all these different “flavors” of disordered eating have in common rather than what separates them? Is it not true the most people, even medical professionals, tend to identify and define an eating disorder in terms of how someone looks or how overweight or underweight they appear? After all, how can one suffer with an eating disorder if they don’t appear emaciated or massively overweight? And, how is it possible someone can claim to have an issue with binge eating and not appear obese? It would seem many people who do not have first hand experience of what an eating disorder is about would “miss the boat” in this respect. Truth be said, this is similar to what most people were led to believe about alcoholism and drug addiction: alcoholics all wear sneakers, trench coats, and live under bridges while all drug addicts live on the streets and steal money for drugs, and so on. We know differently today. The overwhelming majority of chemically dependent people cannot be “picked out of a crowd.” That said, I’d suggest we revisit the stereotypes many of us have with respect to eating disorders.

Assumption 2: Eating Disorders are better defined by the degree ones’ relationship with food and/or body image diminish the quality of a person’s’ life. [Defining an eating disorder in terms of what someone weighs, although the most common measure used, is likely the least effective way to measure it’s severity].

Inherent in this assumption are eating disorders, regardless of “type,” have in common what I would describe as an addictive or, if you prefer, compulsive set of behaviors that represent a similar “cluster” of characteristics associated with addiction. Let’s examine this “thesis” for a moment and compare anorexia, bulimia, and binge eating disorder through the prism of an addiction model. In doing so, let’s, for the time being, suspend out stereotypical beliefs about “appearance” associated with each type of eating disorder. Let’s look at the most recent set of criteria for dependency [aka addiction] accepted by the medical community*.

* American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition

Diagnostic Criteria for Substance Dependency

1-Tolerance (marked increase in amount; marked decrease in effect)

Anorexia-continued weight loss to gain same effect, bulimia and binge eating disorder, frequency and amount will increase to achieve same effect

2-Characteristic withdrawal symptoms; substance taken to relieve withdrawal

In many instances, albeit not as “dramatic” as drug withdrawal, the phenomenon of craving as well as symptoms of irritability, loss of concentration, and physical symptoms similar to hypoglycemia are experienced

3-Substance taken in larger amount and for longer period than intended

Weight loss [anorexia] amount of food and frequency of episodes more than intended [bulimia and binge eating disorder]

4-Persistent desire or repeated unsuccessful attempt to quit

All eating disorders – attempts to stop may include restricting in order to avoid binge eating or purging, attempting to eat but unable to adequately nourish [anorexia]

5-Much time/activity to obtain, use, recover

Common to all eating disorders – time, money, energy to sustain eating disordered behaviors and increased time needed to recover from effects

6-Important social, occupational, or recreational activities given up or reduced

Common to all eating disorders – social isolation as well as diminished activities that interfere with eating disordered patterns

7-Use continues despite knowledge of adverse consequences (e.g., failure to fulfill role obligation, use when physically hazardous)

Common to all eating disorders- continued eating disordered behaviors despite physical, emotional, social, financial consequences

As mentioned, the committee of the American Psychiatric Association assigned the task of setting up these criteria for substance dependency [aka addiction] has most recently generalized these criteria to include all substance dependencies. It goes further to recommend that a minimum of only three of these criteria [from a total of seven] need to be met in order to justify the diagnosis of substance dependency.

When applied to eating disorders, the common ground becomes apparent when one applies the criteria to eating disorder behavior[s]. Although some would argue that food is not an addictive substance, that debate goes beyond the scope of this article. The point is that both substances and behaviors are capable of emerging as addictions. Some of us in the professional community have come to delineate between substance dependency and addictive patterns of behavior by coining the term “process addictions.” As far as I’m concerned, “a rose is a rose no matter what you care to name it.”

Perhaps the following quote from the American Psychiatric Association’s task force on addiction best summarizes the true nature of addiction, and de facto, an eating disorder.

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in the individual pursuing reward and/or relief by substance use and other behaviors. The addiction is characterized by impairment in behavioral control, craving, inability to consistently abstain, and diminished recognition of significant problems with one’s behaviors and interpersonal relationships. Like other chronic diseases, addiction involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death”.

To see if “the shoe fits”, you might take the quote above and simply insert the phrase eating disorders in lieu of the word addiction. Likewise, the words “restricting, purging, binge eating, and so forth could be interjected. In my professional experience, the shoe fits all too well. It may be time to look at an eating disorder with respect to its real nature rather than surface appearances. The implication for treatment and long term recovery are profound.

Marty Lerner, Ph.D.

Author's Bio: 

Dr. Lerner is the founder and executive director of the Milestones in Recovery Eating Disorders Program located in Cooper City, Florida. A graduate of Nova Southeastern University, Dr. Lerner is a licensed and board certified clinical psychologist who has specialized in the treatment of eating disorders since 1980. He has appeared on numerous national television and radio programs that include The NPR Report, 20/20, Discovery Health, and ABC’s Nightline as well authored several publications related to eating disorders in the professional literature, national magazines, and newspapers including USA Today, The Wall Street Journal, New York Times, Miami Herald, Orlando and Hollywood Sun Sentinels. An active member of the professional community here in South Florida since finishing his training, Dr. Lerner makes his home in Davie with his wife Michele and daughters Janelle and Danielle and their dog, Reggie.

Professional Memberships:

- American Psychological Association [APA]
- Florida Psychological Association [FPA]
- National Eating Disorders Association [NEDA]
- National Association for Anorexia and Associated Disorders [ANAD]
- Binge Eating Disorders Association [BEDA]
- National Association for Anorexia and Bulimia [ABA]
- Florida Medical Professional Group [FMPG]
- National Association of Cognitive Therapists
- International Association of Eating Disorder Therapists [IADEP]

Prior and Current Affiliations:

- Founder and director of Pathways Eating Disorders Program [1987-1994]
- Clinical Director, Eating Disorders Unit at Glenbeigh Hospital, Miami, Fla.
- Clinical Director, Eating Disorders Unit at Humana Hospital Biscayne, Miami, Fla. [1982-1987]
- Founder and CEO, Milestones In Recovery’s Eating Disorders Program, Cooper City, Fla. [1999- current]
- Florida Physicians Resource Network [2005-current]