Part I: What are Eating Disorders?
Eating disorders are serious mental illnesses that can sometimes be deadly in their most severe forms. The American Psychiatric Association defines them as Feeding and Eating Disorders (FEDs) that consist of persistent disturbance around eating, such as unusual eating behaviors that cause the body to absorb the food in an unhealthy manner. More specifically, these eating behaviors are considered “disorders” because they affect one’s ability to function healthily in many areas such as biologically, psychologically and socially. 70 million people worldwide experience these forms of FEDs at least once in a lifetime; they affect all races, ethnicities and genders, according to the World Health Organization.
There are 8 types of FEDs, the most common ones are:
In this blog, you will understand what these common eating disorders are and how they affect individuals.
Anorexia Nervosa (AN)
AN characterized by severe restriction of food that results in extremely low body weight. In the case of AN, low body weight is considered less than what is minimally normal for adults and less than what is minimally expected for children/adolescents according to international standards of a healthy body mass index according to one’s age, height and weight.
AN is also characterized by a person’s intense fear of gaining weight, this fear is often so powerful that it can actually interfere with the person’s ability to gain any weight. Additionally, AN causes an imbalance in how one perceives his/her in body and self. AN is the most deadly of all mental health conditions and those who experience it do not recognize how dangerous it is. The starvation that characterizes AN ultimately causes organ failure at its most extreme episodes, which leads to slow death. Those who survive AN may experience reproductive complications as the body goes into starvation mode, it uses the little fuel it gets to keep the main bodily functions operating such as breathing and brain activity. So, the first thing the body deprioritizes is fertility, males tend to experience low levels of testosterone while females stop menstruating. In addition, AN can also lead to permanent brain damage. Although their body is severely underweight, when they look in the mirror all they see is a person who is overweight. It is truly devastating. However, there is good news. AN is treatable. Often, a multidisciplinary treatment approach consisting of psychotherapy, psychiatric medication, medical attention and nutritional plans is ideal if the individual has access and resources. For severe cases, hospitalization is provided in medical or psychiatric units designed to normalize eating patterns.
Bulimia Nervosa (BN)
In my experience as a Counseling Psychologist in Cairo, Egypt, Bulimia Nervosa and Binge Eating Disorder are the most prevalent, especially among females.
BN is characterized by recurring episodes of binge-eating and compensatory behaviors. Binge eating is the behavior of eating large amounts of food in a short period of time and feeling a lack of control in that moment. In other words, a binge is eating too much in too little time compared to others, while also feeling like one cannot stop. My clients tend to describe this as an uncomfortable feeling of being full that is difficult to control. The binge is usually followed by a sense of guilt that triggers the urge to compensate for that large amount of food and calories. There is more than one way to compensate, such as induced vomiting (also known as purging), excessive exercise or periods of starvation, and overuse of laxative medication. These compensatory behaviors provide a sense of relief because although they ate too much, they are able to get rid of the calories somehow. Some individuals find comfort in using multiple compensatory behaviors at once. For example, after a binge an individual may excessively exercise and take a few pills of laxatives, then and only then does the relief kick in.
Binges are often caused by a situation that causes negative thoughts and emotions about oneself. They tend to lead to guilt and shame. I once had a client that ran 1.5 laps on a track to burn-off the calories after eating a few strawberries.
Those who experience BN tend to experience similar physical effects as those who experience AN. The difference is that those with BN do not have extremely low body weight; They can appear to have any body weight and shape. In addition, BN causes individuals to shy away from smiling or laughing in public as their teeth tend to erode and turn yellow from the repetitive vomiting. This happens because the acid in the vomit erodes the protective layer of their teeth, called enamel.
Interestingly, BN is also associated with misuse of drugs and sometimes addiction. According to Eating Disorder Hope, this may be due to several commonalities such as the individual’s natural tendency to give into compulsive and impulsive behaviors, which can be due to genetics, as well as trauma, which will be discussed further in the following sections of this blog.
The good news is that BN is highly treatable. However, only 6% of those who struggle with BN get treatment in the USA, that leaves me to assume that a lesser percentage get treatment in the Middle Eastern/North African (MENA) region as mental health; That is because it is still heavily stigmatized in this part of the world. Although younger generations in the MENA region seem to be more open about mental health help, and mental health professionals are actively spreading awareness and trying to break the cultural stigma toward it, especially in Egypt. Although we are getting better, I personally believe we still have a long way in guiding our culture to understand and embrace mental health. However, we are certainly on the right track and more individuals are realizing that it is okay to not be okay, and it is certainly okay to get professional help.
Binge-Eating Disorder (BED)
BED is similar to BN, but instead of binging and compensating for the extra calories eaten, a person struggling with BED only binges. Instead of getting rid of the food, they keep it all in, which causes the individual to experience intense feelings of guilt,
shame and disgust of the self due to the binge. Fortunately, those who experience BED are more likely to seek treatment compared to those with BN.
Part II: Causes of Eating Disorders
Eating disorders are caused by genetics, professional expectations, low self-esteem, cultural factors and psychological trauma.
Developing research suggests that over 50% of the risk of developing eating disorders are based on genetics.
In the case of models and athletes,professional expectations cause the development of eating disorders as their success is attributed to a specific body size and image.
Low self-esteem is one of the main causes of the development of eating disorders. An individual may learn to devalue their self as a whole and their body image due to:
-The media’s depiction of an ideal body image that is often unrealistic and not naturally attainable. For example, parents can teach their children to have a healthy body image at home, yet the media portrays females with perfect noses, perfectly proportioned bodies, thin waist, wide hips, and large lips. In reality, individuals are not born with such perfection all around their bodies. Similarly, attractive males in the media are portrayed as tall, physically fit, muscular, with wide shoulders, a hip haircut and glowy skin; This is contrary to reality, males come in all shapes, colors and sizes. The media including social media, celebrities, and fictional books often favor an ideal look for both males and females, which makes individuals feel like they are not as valuable as they compare themselves to those depicted in the media. Needless to say, those portrayed in the media have a team of beauty experts to enhance and alter their natural look to fit the ideal image.
-Ineffective Parenting is another cause of low self-esteem that can lead to the development of eating disorders. This happens when parents with a caring intention overanalyze their children’s eating habits to the extent in which they put them on strict diets at a very early age, usually under 10-years-old. Although parents have a caring intention of teaching their child to lead a healthy lifestyle, it is often communicated to children with fear. For example, parents teach their children that they must restrict themselves from eating sweets, treats and chips or else they will “get fat and be ugly.”
When children hear this from their parents, at an early and tender age, they quickly learn that their self-worth is equated to how they look. This causes them to see food as good or bad, instead of fuel for survival. When this happens, children develop feelings of guilt and shame when they eat sweets and chips, and hide to eat them so they do not get in trouble. When this happens, the child often eats very fast (almost like a binge) and in shame because they’ve learned that this food is bad therefore, s/he is bad for eating it. Parents may be in denial or simply unaware of this as they think they’re teaching their children to reach their full potential, yet in reality they teach them not to accept themselves and place an emphasis on appearance rather than manners and characteristics. As children grow up to be adolescents, they learn to criticize themselves as their parents do.
Research suggests that Arab females experience internal conflict due to the westernization of the Arab world. As they are usually caught between the clash of traditional and western values. A young Arab girl may be taught to cover her body
modestly, yet sees a different expectation of women when she logs into Instagram and sees
celebrities, influencers and peers dressing in a more Westernized manner than is expected of her at home. This is very confusing and distressful
for the young girl because she is caught between being a good girl in the eyes of her family
or being cool, fitting in and feeling good about herself and her body. This also causes a
generational clash between the parents and the children, ultimately leading to difficulty for
girls to cope. That is when FEDs begin to develop because they feel they have no control
over their life or choices. Thus, they choose to control the one aspect others cannot control
in their life, which is what goes into their bodies: food.
Another cause of FEDs is psychological trauma, which is coped with by choosing to control
their own emotional suffering by engaging in maladaptive eating patterns known as FEDs.. For example, a person who lost his job, home and loved ones due to an earthquake may have difficulty adjusting to these traumatic events that were certainly not his choice or in his control. This person may be prone to developing an eating disorder as a way of gaining a sense of control over the emotional pain, because he can control what he puts into his body.
Overview of Treatment
Fortunately, eating disorders are treatable. The main step in psychological therapy is to work with a mental health professional to identify underlying emotions, thoughts and behaviors that may have originally caused the individual to develop the disorder.
Often, a multidisciplinary treatment approach consisting of psychotherapy, psychiatric medication, medical attention and nutritional plans is ideal if the individual has access and resources. For severe cases, hospitalization is provided in medical or psychiatric units designed to normalize eating patterns.
In The Therapy Room
In therapy, clients are usually aware of their eating patterns, yet sometimes others’ are not and usually come in to work on their emotional concerns such as anxiety, depression or relationship issues. As the client and therapist work together in the therapeutic process, they begin to see how their emotional distress has affected their eating habits. Both client and therapist work together to reduce the shame and address the eating disorder as its own entity, while working on resolving the emotional distress that originally caused it to develop.
Through therapy, clients learn that FEDs are unhealthy coping strategies that surface as a result of underlying emotional distress that causes them to perceive food as good or bad, rather than bodily fuel for survival. In other words, people develop such eating behaviors to deal with their problems, but they are often not the main problem, until they begin to affect one’s ability to function normally. However, there is something greater that causes them to engage in those eating habits because whenever there is an eating disorder, there is usually a more significant problem that is causing it.
So if we were looking at an iceberg, the visible part on the top would be the eating disorder, and underneath the surface of the water would be the underlying problems that contribute to it, such as depression and anxiety, which have their own origins as well, perhaps parent-child issues, low self-esteem, body image issues or trauma. In other words, eating disorders are unhealthy coping strategies that people use when they feel their life is out of their control. It is often a way to cope with emotional pain and prolonged periods of distress. As client and therapist work on resolving emotional issues and also work together to develop healthier coping strategies that work for the individual over time. This is usually the overall process that occurs throughout various therapeutic approaches. Different types of therapists may take a different route, however they all have the same goal to work on the underlying problems and ultimately replace the eating disorder with healthy, sustainable coping strategies over time. It is a process that takes time and patience, yet the road to recovery is worth every moment.
Part III: What is Emotional Eating?
On the other hand, emotional eating (EA) is not an eating disorder (FEDs).
EA is not a mental health disorder, rather it is a behavioral pattern of using food to regulate an emotion. When people emotionally eat, they usually have a healthy relationship with food and can function mentally, psychologically and socially, which is the complete opposite for someone experiencing FEDs. Most of us are occasionally emotional eaters; that is, we eat to celebrate and soothe our emotions when we are not physically hungry. For example, we emotionally eat when we are happy, that is when we have lavish feasts during holidays, celebrate promotions, weddings and birthdays. We also emotionally eat when we are sad, lonely, bored or angry. Most commonly, we emotionally eat when staying up late, feeling nostalgic, angry, missing someone, after a break-up or when avoiding an argument and we do that to fill an emotional void that we feel within.
The reason many people use food as a way to soothe emotions is simple. As humans we are emotionally connected to food. The very first thing we learn as we take our first breath into this world is the association between love and comfort; as soon as our birth mother holds us for the very first time, she puts us beside her breast, nursing us with breastmilk. This experience repeated throughout our early years until the brain associates love and comfort with food. Each time we cried as infants, our caregivers gave us food, be it breastmilk or formula, and as we grew, solid foods were offered as a reward for good behavior or distraction from distress. As adults we do the same thing with ourselves. You may find yourself eating when distressed to soothe or reward yourself after a big accomplishment or long day. Interestingly, I find that many clients emotionally eat specific nostalgic foods that take them back to a simpler time when they were children, such as chocolate, cake spaghetti and candy; it’s unique to each individual and usually hyperpalatable (high in sugar and fat) for immediate satisfaction.
EA normal behavior when done in moderation and on occasion. However, when done on a daily basis, EA shows its dark side. Research indicates that EA as a response to negative emotions interferes with weight-loss, increases body mass index; it also immediately induces feelings of guilt because eating to fill an emotional void has no end, unlike physical hunger when the body feels full. In most cases, one can go on and on through multiple bags of chips, before s/he realizes that food is not solving the emotional problem, and the void still exists; This triggers guilt and anxiety about the excessive calories consumed. EA that occurs on a daily basis is unhealthy and indicates there is an underlying emotional problem that can be easily overcome in psychological therapy.
The similarity between Emotional Eating and Eating Disorders is the internal need for control. The difference between them is that those with EA just want to control an emotion in the moment by using food to feel comfortable, not to control their life or suffering as those with FEDs do. Moreover, a person experiencing FEDs experiences difficulty with daily functioning.
There is a very fine line between EA and FEDs, no wonder why many confuse EA for FEDs.
If you or someone you know is experiencing FEDs or constant EA, know that psychological help is near accessible in-person and online, especially in Cairo, Egypt. The first step to decide to get help is the bravest and I strongly encourage you to give it a try because it can truly make a positive difference in your life.