The root of eating disorders is not necessarily a result of weight management, but a way to help manage negative emotions, researchers report.
Despite their prevalence – the problem is worldwide – myths about eating disorders abound. Such as that they are a choice.
They are not. Or they’re not a big deal. They are. Or that a person with an eating disorder is always severely underweight. Not always.
As a licensed psychologist and psychology professor, I find it’s common for my clients and students to say “A little food helps me with my anxiety” or “I’m not thin enough to have an eating disorder.”
Such beliefs often prevent people from recognizing they have a problem. More is involved in an eating disorder than food, or body image.
Someone gripped by one is attempting to regulate some very difficult and complicated emotions.
What is an eating disorder?
Eating disorders fall into three basic categories: disorders of restriction, or anorexia; bingeing, known medically as binge eating disorder; and bingeing followed by compensation – such as self-induced vomiting – which is called bulimia.
Unpacked further: Restriction means limiting calories so much that weight loss is more than expected for a given height and weight.
This does not necessarily mean the person will appear emaciated. Someone who was at the 90th percentile for weight, for example, could still be considered anorexic if they reduced their weight to the 70th percentile.
Bingeing is more than simply overeating. It’s out-of-control eating, leading to extreme feelings of fullness and guilt, typically within a couple of hours after a meal.
By bingeing, a person can check out of life circumstances to focus only on food.
With bulimia, a binge is followed by an action to compensate for the calories consumed. Purging is one of them, but there are others, including exercise, particularly when it’s taken to an extreme.
Although exercise is often overlooked as a form of compensation, a person addicted to it has more than three-and-a-half times the likelihood to be diagnosed with an eating disorder than a person a without one.
It should be emphasized that not all of these disorders always result in weight loss. Those with binge eating disorder and bulimia may be at or above expected weight.
The root of an eating disorder
Eating disorders aren’t about managing weight. Rather, they’re a way to manage emotions. When my clients describe what it’s like to restrict themselves from food, they often talk of being “empty” and feeling “numb” to the world.
An eating disorder is not about managing weight; it’s about managing emotions.
Take someone dealing with a trifecta of guilt, shame and embarrassment.
Bingeing is exceedingly effective at burying these emotions.
So is compensation, a tool to give the sufferer a break from the emotional turmoil.
The relief they receive is a reinforcer, and it’s extraordinarily powerful. Purging, overeating, compensating – it all feels good. Very quickly, the pattern is repeated.
Simply changing eating patterns won’t work. Instead, sufferers must first identify the feelings they’re experiencing. Then comes a search for better strategies to deal with those feelings.
In the interim, nothing feels as good as the eating disorder. But slowly, as healthy behaviors take over, they become more reinforcing than the disorder.
With Feb. 24 marking the beginning of National Eating Disorders Awareness Week, there’s one thing you need to remember if you know someone with an eating disorder.
They are experiencing significant emotional pain; the eating disorder is an attempt to communicate that pain.
If food or exercise appears to be running the life of a family member, friend or colleague, you can help by focusing on them and their lived experience – and not exclusively on the food.
Eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (EDNOS), are amongst the most serious of mental illnesses (see APA, 2000; Nielsen, 2001; Papadopoulos, Ekbom, Brandt, & Ekselius, 2009). EDNOS (DSM‐IV‐TR, APA, 2000), rather than other specified feeding or eating disorder (ED; DSM‐V, APA, 2013), is being referred to in the current review as the studies reviewed included participants diagnosed with an ED based on the older classification system.
These disorders involve the common concerns about gaining weight and associated behaviours to lose weight including food restriction and purging (see APA, 2000). Comorbidity with other psychiatric illnesses is very common including anxiety and depression (O’Brien & Vincent, 2003; Steinhausen, 2002).
Patients with AN are often resistant to change and recover with there being up to a 50% relapse rate (see Fairburn, 2005; Pike, 1998).
This is due to the lack of motivation to change because EDs often play a functional role (Cockell, Geller, & Linden, 2002; Fairburn, Shafran, & Cooper, 1999; Geller, Williams, & Srikameswaran, 2001; Serpell, Treasure, Teasdale, & Sullivan, 1999; Vitousek, Watson, & Wilson, 1998), with early modern theorists suggesting that AN serves as a means of gaining control during a time when a perceived lack of control is common (see Bruch, 1978; Crisp, 1997).
The present review explored the qualitative literature on emotions and EDs. As this review demonstrates how individuals with EDs experience and manage their emotions, there will be a consideration of emotion regulation theories including the SPAARS model of EDs (SPAARS‐ED an acronym for the Schematic, Propositional, Associative, Analogical Representations emotions may have; Fox & Power, 2009; Power & Dalgleish, 2008), the cognitive–interpersonal maintenance model of AN (Schmidt & Treasure, 2006; Treasure & Schmidt, 2013), and the integrative neuroscience model of AN (INTEGRATE‐AN; Hatch et al., 2010).
The role of emotions and emotional regulation in EDs, and particularly AN, has long been considered an important feature in the aetiology and maintenance of the disorder (Bruch, 1973), but this has not been prioritized in research and treatment programmes until recently (see Fox, Federici, & Power, 2012a; Haynos & Fruzzetti, 2011).
Emotions are comprised of five different categories, namely, happiness, sadness, anger, fear, and disgust, with more complex emotions being built on a combination of these basic categories (Ekman, 1982, 1992a, 1992b).
Emotions play a key role in everyday functioning in that they facilitate understanding of events and responses to them based on the individual’s appraisals (Fox et al., 2012a; Oatley & Johnson‐Laird, 1987; Power & Dalgleish, 1997; Zajonc, 1980).
Emotion regulation theories have been used to help understand the role of emotional functioning in EDs (Gross, 1998, 2002). Emotion regulation relates to processes individuals engage in in order to influence the emotions they experience, when the emotions are experienced, the degree to which they are experienced and whether they are expressed (Gross, 1998; Sloan & Kring, 2007).
Studies have illustrated relationships between deficits in emotion regulation strategies and numerous psychiatric disorders and EDs (Aldao, Nolen‐Hoeksema, & Schweizer, 2010; Danner, Evers, Stok, van Elburg, & de Ridder, 2012; Wolgast, Lundh, & Viborg, 2013). ED symptoms including food restriction, purging, and binge eating serve as a means of “escape” from negative emotions due to their numbing effect on negative arousal (Haynos & Fruzzetti, 2011). Thus, patients with EDs may be using their ED symptoms and related behaviours as a means of regulating their emotions by directing them towards the body (see Aldao et al., 2010; Danner et al., 2012).
The SPAARS‐ED (Fox & Power, 2009; Power & Dalgleish, 2008) builds on modern theories on emotions and the research literature suggesting the role of emotions in EDs (Fox & Power, 2009). The SPAARS model suggests that emotions can be categorized into five basic domains: happiness, sadness, anger, fear, and disgust (Fox & Power, 2009).
A central feature of the model is that individuals learn which emotions are acceptable for them to express, that is, ego‐syntonic, and which ones are considered unacceptable for them to express, that is, ego‐dystonic, and as a result are inhibited by the individual (Fox & Power, 2009; Power & Dalgleish, 1997).
As part of development and growing up, individuals learn which emotions are “acceptable” or not acceptable to express; for example, individuals learn that anger is a dangerous emotion (see Fox, 2009; Fox & Power, 2009).
Emotions, which are considered to be ego‐dystonic and potentially “dangerous” for the individual to express, due to them being perceived as negative and having the potential for them to cause rejection, are suppressed using ED behaviours and are directed towards the body (Fox & Power, 2009).
By contrast, the cognitive–interpersonal maintenance model of AN (Schmidt & Treasure, 2006; Treasure & Schmidt, 2013) proposes that certain factors predispose individuals to AN.
In addition, the individual’s engagement in food restriction and the effects of starvation make these risk factors become more prominent in their influence on the individuals behaviours and are responsible for the maintenance of the disorder (Schmidt & Treasure, 2006; Sternheim et al., 2012; Treasure & Schmidt, 2013).
The model proposes that emotional avoidance through the avoidance of social interactions is also evident amongst individuals prior to the onset of an ED. Engaging in ED behaviours and the effects of starvation further exacerbates these social and emotional skills and therefore become maintenance factors for the disorder (Schmidt & Treasure, 2006; Treasure & Schmidt, 2013).
In addition, the integrative neuroscience model of AN (INTEGRATE‐AN; Hatch et al., 2010), a stress‐diathesis model linking emotions to ED behaviours in a temporal sequence (Hatch et al., 2010), suggests that certain genetic and constitutional risk factors, including puberty changes (see Kaye et al., 2005; Kaye, Frank, Bailer, & Henry, 2005; Sisk & Foster, 2004; Treasure, 2007), make individuals more sensitive to negative emotional cues and that this coupled with a stressful life event; for example, starting high school or death of a close one can trigger AN (Hatch et al., 2010).
The hypersensitivity to negative emotions also results in a feeling of loss of control, and as a result, such individuals engage in food restriction, which serves as a maladaptive strategy for regulating their emotions (due to the numbing effect food deprivation has on emotions).
This “starvation syndrome” exacerbates predispositional factors and results in the maintenance of the ED (see Hatch et al., 2010).
The above research and models demonstrate that emotions play an important role in EDs. However, the evidence referred to has been drawn primarily from quantitative research.
In recent years, there has been some qualitative research in EDs, with particular consideration on the role of emotions in EDs. However, to date, there has been no systematic review of these qualitative studies.
The aim of the present review is to conduct a metasynthesis of studies considering emotions in EDs in order to gain an in depth account on how individuals with EDs experience various emotions and the strategies they use to manage them.