Perspective: Disordered Eating

Introduction

Have you ever heard someone describe themselves as “hungry for love”? Or conversely, so “heartbroken” that they cannot eat? Or more extreme, that they are “dying to fit into this dress”? If you are East Asian, there is a good chance you have been asked “have you eaten rice today?” instead of “how are you?” And if you are feeling ill, there may well be a dish, personally and culturally significant, that can make you feel a bit better—one preferably made by, or at least following the recipe of, a parent or grandparent. At the core of these links are expressions of care. Elsewhere in this book are descriptions of how food may be used as a tool for cultural ritual and social cohesion. Here, we consider how food may also work within these sociocultural frames to serve individual psychological needs. One person may fail to find the love they are “hungry” for in their environment and turn to food instead. Another may fail to live up to unhealthy body image norms and turn away from food, despite mounting hunger and malnutrition.

Indeed, food is a daily necessity and key to sustaining life and health. The search for food is thus essential, not only to being human, but to being any living thing. Biological evolution brought teeth and tongues, throats and stomachs to the animal kingdom. Those who ate lived to survive and procreate. In this sense, food and eating are central and truly universal. But then in humans, cultural evolution also brought a series of innovations, from tools for hunting and gathering, to agricultural techniques, to contemporary mass-production and mass-marketing. Moreover, cultural evolution built innumerable innovations on top of the basic biology of food. To take one example, disgust, which is an emotion grounded in the ancient physiological imperative to expel potential poisons. Yet this same emotion system also scaffolds a very complex, culturally shaped, set of responses: moral disgust.^[1]

The human experience of food and eating is at once deeply shared and personally idiosyncratic, biologically grounded and culturally shaped. One lens through which to view this complexity is that of disordered eating: the various ways in which our experience of food and eating goes wrong. As with any other form of what are commonly called “mental disorders,” or psychopathology, we can understand disordered eating at the complex intersection of three levels: culture (and society); mind (and behavior); and brain (and genetics).^[2] In this chapter, we consider some of the major ways in which eating can go wrong, considering several disorders described within the psychiatric manual commonly used in North America: The Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. We look first at emotional distress, in which problems of anxiety and depression can lead to weight and appetite change. Then, we turn our attention to the eating disorders of anorexia nervosa, bulimia nervosa, and binge eating. After describing these disorders, we explore some research-based examples of how they are shaped by culture, mind, and brain. Finally, we will look at traditional and contemporary treatments, noting ways in which food has been used to treat emotional problems, along with ways in which psychological interventions have been used to treat eating problems. We observe effects in both directions because culture, mind, and brain are not three separate domains, but are instead deeply interconnected.

Disorders Affecting Food and Eating

Imagine that you have an upcoming exam or that you are getting ready for a first date. Many people find that increased levels of stress or anxiety will suppress their appetite. For most, the situation passes and the appetite returns—but for someone with an anxiety disorder, appetite may be compromised for a prolonged period of time. This occurs because stress and anxiety lead to arousal of the autonomic system, which leads to many different physiological changes including symptoms that reduce appetite, such as nausea, diarrhea, and a subjective sense of bloating. Chronic sadness or loss of pleasure can also have an impact on appetite, with depressive disorders including weight and/or appetite change as one of the core symptoms. Appetite may be lost because of direct physiological effects of depression on the gastrointestinal system, but also because depression can affect the hedonic pleasure obtained from the senses.^[3] When someone is exceptionally sad, foods that were previously enjoyed and ordinarily very tempting, like chocolate cake or French fries, may be described as unappealing, tasting instead like cardboard.

Stress, anxiety, and depression do not always lower one’s appetite. A sizeable minority of sufferers instead report increased appetite, often accompanied by weight gain. Some people cope with anxiety through what is popularly known as “stress eating.” This phenomenon can be observed, for example, in people who are quitting smoking and no longer experiencing either the subjective calming or the appetite suppression caused by nicotine. One subtype of Major Depressive Disorder, known as “atypical depression,” involves weight and appetite gain, along with other less common symptoms, such as increased sleep. Another subtype follows a seasonal pattern where sufferers are prone to depression during the winter months. A common feature of this Seasonal Affective Disorder is weight and appetite gain, driven especially by powerful cravings for carbohydrates.

DSM-5 also includes a chapter on specific “Feeding and Eating Disorders.” The most widely studied eating disorder is Anorexia Nervosa, characterized by marked restriction of caloric intake resulting in strikingly low body weight. Bulimia Nervosa, meanwhile, involves a pattern of recurrent episodes of binge eating in combination with recurrent compensatory behaviors, such as purging or use of diuretics. A more recent inclusion in the diagnostic system is Binge Eating Disorder, characterized by consumption of a vast amount of food in a discrete period of time. Up to 4% of Canadian women report an eating disorder.^[4] Although men generally face pressure to increase musculature, eating disorder symptoms are observed in some men. There is evidence that these rates, especially among youth, are steadily increasing.^[5]

Focus on Feeding and Eating Disorders

“Convinced that any extra weight would slow her down, and hearing coaches make offhand remarks about whether she had gotten bigger, Ruck began to fixate…

Out with her teammates that evening, Ruck later ducked into a nearby cafe and forced herself to throw up the meal, telling no one. Purging had become as much a part of her routine as 7:30 a.m. laps in the pool.”—Canadian Athlete Taylor Ruck^[6]

Description and Symptoms

Anorexia nervosa. The North American obsession with thinness as an ideal of beauty grew steadily over the 20th century, but came to public attention in the 1980s as several celebrities died from anorexia nervosa–related complications. Others, such as Princess Diana, began to talk openly about their struggles with food and its relation to their self-identity. Anorexia nervosa is a serious disorder associated with a high mortality rate if left untreated. Indeed, death rates are about ten times higher for people with anorexia nervosa compared to the general population.^[7] This disorder is considered “visible,” in that we can often see when a person has abnormally low body weight. Other tell-tale signs include the appearance of fine downy hair on the body (Lanugo hair), loss of tooth enamel, and fidgeting. Subjective experiences of people with anorexia nervosa include intense fear of gaining weight, distorted body image, and difficulty understanding the consequences of the problem. Although some impacts such as gastric complications are reversible, physical features such as low bone density may remain.

“And when I feel lonely, my heart feels hungry and I end up bingeing”

—Demi Lovato, “Simply Complicated,” 2017

Bulimia nervosa. In contrast to anorexia nervosa, bulimia nervosa is an “invisible disorder,” as those who suffer from it are often normal weight, or even overweight. A person struggling with this disorder may thus be able to keep their overwhelming hunger a secret for a very long time. An individual with bulimia nervosa will experience repeated episodes of binge eating, especially of highly palatable (e.g., ready to consume, high calories) and easy to purge (soft texture, mild flavour) foods, such as pizza, ice cream, or donuts. These episodes are not like the overeating you may have occasionally indulged in at a holiday or celebration with good, plentiful food. Rather, a binge averages 3,400 calories—and up to 10,000 calories—in a single episode, along with a subjective sense of little or no control during these times. The sufferers then engage in various activities to counteract the feared weight gain, including: self-induced vomiting; misuse of laxatives, diuretics, or other medications; or excessive exercise. Over time, a person with bulimia nervosa may experience serious physical complications.^[8] Some may find it more difficult to convince their body to purge, further worsening mood.

Binge eating disorder. Binge eating disorder has received much less research attention, as it is a relatively new addition to the diagnostic system. As in bulimia nervosa, people with binge eating disorder will regularly eat large amounts of food in a short period of time. Unlike bulimia nervosa, however, they do not engage in compensatory behaviors. Moreover, people with binge eating disorder are likely to eat for reasons other than hunger, such as coping with stress or loneliness, and find this behaviour to be significantly distressing. Subjectively, they report low self-esteem, even self-hatred, as a consequence of the binges; they often report feelings of repressed anger and depressive symptoms.^[9] Although people with binge eating disorder are often overweight or obese, some may have a body weight within the normal range. Now that this disorder has been admitted into the DSM and formally defined, we should expect to see more research on it in the future.

Causes and Contexts

Culture and society. In the 1980s and 90s, anorexia nervosa was thought to be a disorder of young, white, upper class, Western women. This is no longer the case. As industrialization and globalization increase the reach of the internalization of Western beauty ideals through media, including social media, so too does the prevalence of eating disorders increase around the world. For example, in the mid-1990s, after television was introduced to the island of Fiji, eating disorders that were previously unheard of escalated dramatically.^[10] Anorexia nervosa and bulimia nervosa were previously thought to be infrequent in China, but this may have been because many Chinese eating disorder sufferers lacked the “fear of fat” required for a DSM diagnosis. Moreover, there is evidence from Hong Kong that greater cultural familiarity with Western concepts of eating disorders has actually shifted the symptom presentation of these disorders, closer to Western norms.^[11] Eating disorders are especially common in social subgroups where body image is particularly important, such as models or dancers. Bulimia nervosa in particular seems to affect ethnoracial minority women in North America.

Mind and behavior. People suffering from eating disorders are likely to have distorted thoughts, especially about their body but also regarding their self-esteem and relationships with others. Some research suggests that individuals with eating disorders may have difficulty being aware of their own bodily sensations (like being hungry or satiated). Childhood trauma and mood difficulties, including with depression and anxiety, are also linked with eating disorders. Anorexia nervosa stands out as having a particularly strong association with obsessional self-control,^[12] with sufferers reporting that they experience a feeling of reward in their ability to exert control to override their hunger instinct and “successfully” limit their eating. People with bulimia nervosa may be more prone to act impulsively and they may also be more likely to prefer novelty and stimulation.^[13] They may be particularly prone to being people pleasers and may feel an averse reaction to negative social interactions, which may even trigger a binge. People with binge eating disorder may find that they use food to avoid, cope with, or “numb out” negative emotions.

Brain and genetics. A child who restrains their eating is more likely to have a mother with anorexia nervosa, or a family with high expectations for their child or one that emphasizes the importance of weight.^[14] Genetic studies suggest that inheritance plays a role in eating disorders and that chemical messengers in the brain (neurotransmitters)—such as serotonin and dopamine, responsible for regulated mood and feelings of well-being—are implicated. In many cases, stress may trigger a desire to eat an abundance of food containing carbohydrates, which help the brain to create and release serotonin, in an effort to calm the body down. Unfortunately, in both bulimia nervosa and binge eating disorder, the brain and body simply do not register the chemical message that the body is now satiated. Some studies have even shown that foods high in carbohydrates and sugar present the brain with such a powerful reward that it overrides the body’s signals of being full and even of the associated pain. Indeed, foods high in sugar trigger the same reward hormone (dopamine) in the same brain pathway associated with addiction to narcotics.^[15]

Treatment Interventions

Antidepressant medication is often incorporated into eating disorder treatment, as mood (depression/anxiety) and eating problems are often co-occurring. Appetite and weight symptoms in mood disorders respond to anti-depressants but prescribers need to be careful: many of these medications have weight gain as a side effect,^[16] although some of them instead can lead to nausea and weight loss. Anorexia nervosa, in particular, can demand quite radical interventions because it is potentially life-threatening. The most immediate goal of treatment is to introduce food incrementally, safely increasing weight to an acceptable level. In some cases, such treatment (food) may need to be given involuntarily.

Psychological approaches to anxiety, depression, and eating disorders often include interventions grounded in cognitive behavioural therapy (CBT). For people with eating disorders, the aim is to help develop normal eating patterns; a similar goal can be seen in CBT for anxiety or depression when applied to weight and appetite symptoms. Eating journals may be employed as a technique to keep track of moods and to connect various emotional states to eating. CBT can also be used to bring attention to internal processes—such as stress, sadness, or anger—and to exchange unhealthy coping mechanisms with healthy coping (e.g., exchanging binge eating for breathing exercises). Exercise may also be utilized to improve mood and increase bodily awareness. For bulimia nervosa, the core of this approach is a focus on dismantling unhealthy beliefs about the self and the body. Individuals who binge may learn to override the impulse both to continue eating after eating a ‘forbidden’ food and also to purge in response. People who previously binged on pre-packaged foods may learn to cook and prepare foods carefully, thereby re-establishing a new relationship with food.

The sociocultural context should also be considered when discussing treatment. In many cultural contexts, food is an essential part of maintaining or recovering good health. In Traditional Chinese Medicine, various conditions—which can include mood or appetite symptoms—are understood as deficits of hot and cold, wet and dry.^[17] Specific foods are then prescribed to help correct any imbalances. In Ayurvedic Medicine, disorders might arise through a person eating foods that are not compatible with one’s body type; treatment would then correct this.^[18] In any case, clinicians working with eating disorder patients should not assume that these patients inhabit a cultural world similar to the clinicians themselves. Culturally sensitive treatment involves finding out about the patient’s own beliefs about food, weight, and health, as well as beliefs commonly held in the patient’s community. There are also direct interventions at a societal level, although these are most often implemented by public health officials and policy-makers, rather than psychiatrists or psychologists. For example, some magazines have introduced a diversity of models into their fashion pages,^[19] thereby attempting to widen the definition of beauty, to include a variety of body shapes. Psychological interventions can also help young people to increase their self-esteem and body image satisfaction.^[20]

Reflections

Food and eating can be understood as biological necessities grounded in evolution, as deeply shaped by sociocultural context, and as varying across individual people depending on their temperament, family of origin, social network, and so on. Disordered eating can be understood in a similar manner. Dividing our overall story into sections—on culture and society, on mind and behaviour, on brain and genetics—makes it easier to tell.

This chapter began by considering both North American but also cross-cultural metaphors and analogies linking food and eating with expressions of longing, of pain, and of care for another. We see that human relationships with food and eating are deep and universal. These relationships bring such pleasure, joy, and facilitate connection but when they go wrong, can also be a signal that it is time to pay attention to the confluence of mind, body, and culture where suffering and healing are both possible.

References

American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders (5th ed.).

Attia, E. 2010. Anorexia Nervosa: Current status and future directions. Annual Review of Medicine 61: 425–435.

Bardone-Cone, A. M., Wonderlich, S. A., Frost, R. O., Bulik, C. M., Mitchell, J. E., Uppala, S., & Simonich, H. 2007. Perfectionism and eating disorders: Current status and future directions. Clinical Psychology Review 27 (3). 384–405.

Becker, A. E., Burwell, R. A., Navara, K., & Gilman, S. E. 2003. Binge eating and binge eating disorder in a small‐scale, indigenous society: The view from Fiji. International Journal of Eating Disorders 34 (4). 423–431.

Buhrman, S. 1996. Ayurvedic psychology and psychiatric approaches to the treatment of common affective disorders. Protocol Journal of Botanical Medicine 2. 1–8.

Chentsova-Dutton, Y. E., & Ryder, A. G. 2020. Cultural models of normalcy and deviancy. Asian Journal of Social Psychology 23 (2). 187–204.

Davis, H. 2017. Simply complicated. Youtube.

Fava, M. 2000. Weight gain and antidepressants. Journal of Clinical Psychiatry 61 (11). 37–41.

Flaws, B., & Sionneau, P. 2001. The treatment of modern Western medical diseases with Chinese medicine: A textbook & clinical manual. Blue Poppy Enterprises, Inc.

Frank, G. K., Shott, M. E., Stoddard, J., Swindle, S., & Pryor, T. L. 2021. Association of brain reward response with body mass index and ventral striatal-hypothalamic circuitry among young women with eating disorders. JAMA Psychiatry 78 (10). 1123–1133.

Langlois, K. A., Samokhvalov, A. V., Rehm, J., Spence, S. T., & Gorber, S. C. 2012. Health state descriptions for Canadians: Mental illnesses. Ottawa: Statistics Canada.

Le, L. K. D., Barendregt, J. J., Hay, P., & Mihalopoulos, C. 2017. Prevention of eating disorders: a systematic review and meta-analysis. Clinical Psychology Review 53. 46–58.

Le, L. K. D., Hay, P., & Mihalopoulos, C. 2018. A systematic review of cost-effectiveness studies of prevention and treatment for eating disorders. Australian & New Zealand Journal of Psychiatry 52 (4). 328–338.

Mehler, P. S., Krantz, M. J., & Sachs, K. V. 2015. Treatments of medical complications of anorexia nervosa and bulimia nervosa. Journal of Eating Disorders 3 (1). 1–7.

Polivy, J., & Herman, C. P. 2002. Causes of eating disorders. Annual Review of Psychology 53 (1), 187–213.

Robertson, G., & Brady, R. 2021. Dangerous Games. The Globe and Mail (December 18th).

Rozin, P., & Haidt, J. 2013. The domains of disgust and their origins: Contrasting biological and cultural evolutionary accounts. Trends in Cognitive Sciences, 17 (8). 367–368.

Simmons, W. K., Burrows, K., Avery, J. A., Kerr, K. L., Bodurka, J., Savage, C. R., & Drevets, W. C. 2016. Depression-related increases and decreases in appetite: dissociable patterns of aberrant activity in reward and interoceptive neurocircuitry. American Journal of Psychiatry 173 (4). 418–428.

Singer, M. 2021. Generation America: The Models Changing an Industry. Vogue (September).

Telch, C. F., & Agras, W. S. 1996. Do emotional states influence binge eating in the obese? International Journal of Eating Disorders  20 (3). 271–279.

Vyver, E., & Katzman, D. K. 2021. Anorexia nervosa: A paediatric health crisis during the COVID-19 pandemic. Paediatrics & Child Health 26 (2). 1–2

Wu, J., Lin, Z., Liu, Z., He, H., Bai, L., & Lyu, J. 2020. Secular trends in the incidence of eating disorders in China from 1990 to 2017: A joinpoint and age–period–cohort analysis. Psychological Medicine, Advanced online publication. https://doi.org/10.1017/S0033291720002706